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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211909
Report Date: 08/30/2023
Date Signed: 08/30/2023 04:53:36 PM

Document Has Been Signed on 08/30/2023 04:53 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:BAHIA SCHOOL AGE PROGRAMFACILITY NUMBER:
010211909
ADMINISTRATOR:LEVYA-CUTLER,B.&CUEVA, M.FACILITY TYPE:
840
ADDRESS:1718 - 8TH STREETTELEPHONE:
(510) 524-7300
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY: 65TOTAL ENROLLED CHILDREN: 65CENSUS: 14DATE:
08/30/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Yanci LuceroTIME COMPLETED:
05:03 PM
NARRATIVE
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On August 30, 2023 at 1:43pm Licensing Program Analyst (LPA) Indira Loza met with Site Supervisor Yanci Lucero. Present for the inspection were 14 school-age children. LPA conducted a tour of the facility for a Health and Safety check.

Based on multiple interviews conducted, it has been determined that a child ran away from the facility on more than one occasion and was not reported to CCL.

See LIC 809-D for one Type B deficiency.

An exit interview was conducted with Site Supervisor Yanci Lucero.
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: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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 08/30/2023 04:53 PM - It Cannot Be Edited


Created By: Indira Loza On 08/30/2023 at 04:13 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: BAHIA SCHOOL AGE PROGRAM
FACILITY NUMBER: 010211909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2023
Section Cited
CCR
101212(d)(1)(C)

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(d) Upon the occurrence... a report shall be made... within the Department's next working day and during its normal business hours. (1) Events reported shall include the following:(C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement was not
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The Director shall hold an all staff meeting reviewing what events have to be reported, and how to report Unusual incidents to CCL.
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met as evidenced by: Based on interviews it was determined that a child ran away multiple times on undisclosed dates and the incidents were not reported to CCL which poses a potential Health, Safety, and Personal Rights Risk to children in care.
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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: 08/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023


LIC809 (FAS) - (06/04)
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