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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010206120
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:52:37 PM

Document Has Been Signed on 02/23/2023 03:52 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:BERKELEY YMCA HEAD START - WESTFACILITY NUMBER:
010206120
ADMINISTRATOR:MURRAY, CHERYLFACILITY TYPE:
850
ADDRESS:2009 10TH STREETTELEPHONE:
(510) 848-9092
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY: 70TOTAL ENROLLED CHILDREN: 70CENSUS: 33DATE:
02/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Carlota Hernandez De CruzTIME COMPLETED:
04:02 PM
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On February 23, 2023, Licensing Program Analyst (LPA) Indira Loza and Licensing Program Manager (LPM) Mayla Medoza conducted an unannounced case management in regards to an unusual incident reported to the Oakland Regional Office on February 16th, 2023. The LPA and LPM met with Interim Director Carlota Hernandez De Cruz and Area Manager Joshua Jackson.

LPA and LPM interviewed Director and staff regarding the incident that occurred and watched video footage of the classroom. LPA and LPM will return to continue the case management.

No deficiencies cited during today's visit. Exit interview conducted.
A copy of the report and appeal rights provided to Interim Director, Carlota Hernandez De Cruz.
Notice of Site Visit provided.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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