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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010210354
Report Date: 08/31/2023
Date Signed: 08/31/2023 09:37:37 AM

Document Has Been Signed on 08/31/2023 09:37 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:GRAND LAKE MONTESSORIFACILITY NUMBER:
010210354
ADMINISTRATOR:FAYE OWENSFACILITY TYPE:
850
ADDRESS:466 CHETWOOD STTELEPHONE:
(510) 836-4313
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY: 172TOTAL ENROLLED CHILDREN: 115CENSUS: 89DATE:
08/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Alicia CooperTIME COMPLETED:
10:30 AM
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On 08/31/2023 at 8:45AM Licensing Program Analyst (LPA), A. Curry conducted an unannounced case management inspection to follow up on a self-reported unusual incident. LPA met with the Director, Alicia Cooper, to explain the purpose of today's visit. LPA toured the facility, made observations, conducted interviews, and retrieved relevant documentation. No deficiencies are being cited.


Exit interview conducted, appeal rights were given, and report was reviewed with the director Alicia Cooper.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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