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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010215033
Report Date: 10/27/2023
Date Signed: 10/27/2023 11:58:44 AM

Document Has Been Signed on 10/27/2023 11:58 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:OAKLAND HEAD START - MANZANITAFACILITY NUMBER:
010215033
ADMINISTRATOR:TERRY CHENFACILITY TYPE:
850
ADDRESS:2701 - 22ND AVENUETELEPHONE:
(510) 535-5627
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 12DATE:
10/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TERRY CHENTIME COMPLETED:
12:15 PM
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On October 27, 2023 LPA Tasha Alexander met with center director Terry Chen to discuss a self reported unusual incident that occurred on 9/29/23.

Today an interview was conducted with Ms.Chen and a tour of the facility was conducted.

Based on interviews and observations. There are no deficiencies cited today.

An exit interview was conducted. A notice of site visit was posted.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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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