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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010200115
Report Date: 06/29/2023
Date Signed: 06/29/2023 03:40:29 PM

Document Has Been Signed on 06/29/2023 03:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CHILDRENS COMMUNITY CENTERFACILITY NUMBER:
010200115
ADMINISTRATOR:KATHY CHEWFACILITY TYPE:
850
ADDRESS:1140 WALNUT STTELEPHONE:
(510) 528-6975
CITY:BERKELEYSTATE: CAZIP CODE:
94707
CAPACITY: 52TOTAL ENROLLED CHILDREN: 52CENSUS: 26DATE:
06/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Encian Pastel TIME COMPLETED:
03:45 PM
NARRATIVE
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On June 29, 2023 at 9:22am Licensing Program Analyst (LPA) Indira Loza and Licensing Program Manager (LPM) met with Teacher Encian Pastel. Present during the inspection were 26 children and 11 fingerprint cleared staff. During the visit LPA and LPM toured the facility for a Health and Safety inspection.

During interviews conducted, the LPA found that a couple of incidents had not been reported to CCL which violates California Code of Regulations(CCR) 101212(d).

See 809-D for one Type B deficiency.

An exit interview was conducted with Teacher Encian Pastel
Report and Appeal Rights provided.
Notice of Site Visit must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/29/2023 03:40 PM - It Cannot Be Edited


Created By: Indira Loza On 06/29/2023 at 03:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CHILDRENS COMMUNITY CENTER
FACILITY NUMBER: 010200115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2023
Section Cited
CCR
101212(d)

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(d) Upon the occurrence, during the operation of the child care center of any of the events ... a report shall be made to the Department ...within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be
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The Director shall conduct a training with all staff describing what the report requirements are, and a list of signatures of staff acknowledging they received this training no later than July 30, 2023.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023


LIC809 (FAS) - (06/04)
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