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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010206131
Report Date: 10/03/2023
Date Signed: 10/03/2023 10:40:38 AM

Document Has Been Signed on 10/03/2023 10:40 AM - 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:OUSD - HINTIL KUU CAFACILITY NUMBER:
010206131
ADMINISTRATOR:JONES, CAROLINEFACILITY TYPE:
850
ADDRESS:11850 CAMPUS DRIVETELEPHONE:
(510) 879-0840
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY: 101TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
10/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sharon TraversTIME COMPLETED:
11:00 AM
NARRATIVE
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On 10/03/2023 at 8:45 AM Licensing Program Analyst (LPA), A. Curry conducted an unannounced visit to follow up on a self-reported unusual incident. LPA spoke with the Site Principal, Sharon Travers, via telephone to explain the purpose of the visit. The Site Principal arrived later in the visit. LPA toured the facility and conducted interviews with staff and children. No deficiencies are being cited.

Exit interview conducted, appeal rights were given, and report was reviewed with the Site Principal, Sharon Travers.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2023
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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