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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010209547
Report Date: 01/24/2025
Date Signed: 01/24/2025 12:55:28 PM

Document Has Been Signed on 01/24/2025 12:55 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:BETH SHOLOM PRESCHOOLFACILITY NUMBER:
010209547
ADMINISTRATOR/
DIRECTOR:		CHASE, AMANDAFACILITY TYPE:
850
ADDRESS:642 DOLORES AVENUETELEPHONE:
(510) 357-8505
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 49TOTAL ENROLLED CHILDREN: 49CENSUS: 35DATE:
01/24/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Marianna BallesterosTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
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On January 24,2025 at, 9:45 AM Licensing Program Analyst (LPA) Michael Mathew conducted an unannounced case management inspection LPA met with associate director Marianna Ballesteros and advised her the purpose of the inspection. Director provided LPA a tour of the facility inside and out. There were 35 children and 7 staff in care at the time of the inspection.

LPA arrived at the facility to review staff files. LPA observed that all staff files are up to date,

No deficiency were cited in todays visit

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted, appeal rights were given, and report was reviewed with associate director Marianna Ballesteros

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Michael Mathew
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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