<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415253
Report Date: 08/05/2022
Date Signed: 08/05/2022 03:47:48 PM

Document Has Been Signed on 08/05/2022 03:47 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:DAVIS STREET COMMUNITY CENTERFACILITY NUMBER:
013415253
ADMINISTRATOR:BRIAN WAGENSELLERFACILITY TYPE:
840
ADDRESS:951 DOWLING BOULEVARDTELEPHONE:
(510) 777-9317
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 150TOTAL ENROLLED CHILDREN: 150CENSUS: 0DATE:
08/05/2022
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Trish MurilloTIME COMPLETED:
04:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melanie Otsuji conducted an announced Case Management - Licensee Initiated inspection on today's date, 8/5/2022. LPA was met by Site Program Director, Trish Murillo. Facility is currently closed so no children are present during today's visit. The center has submitted an application for a CAPACITY DECREASE to the SCHOOL AGE license. SCHOOL AGE COMPONENT is currently requesting to decrease from 150 school age children to 60 school age children. The school age program is located in a portable on Roosevelt Elementary School campus. Portable (F01-F01A) is located on the back of Roosevelt Elementary nearest Dutton Avenue. Facility days and hours of operation are Monday through Friday 7AM - 6:00PM. A health and safety inspection was conducted inside and outside. This facility is exempt from square footage and bathroom regulations. Therefore no measurements were taken.

INDOORS: EXEMPT
OUTDOORS: EXEMPT

Davis Street Community Center will have 2 approved classrooms. Facility utilizes Roosevelt Elementary playground and blacktop and does not commingle with the school children. Facility has a sign in/out sheet that allows ample space for full legal signature and records time and date. Per Director, all Opening and Closing staff have current Pediatric CPR/First Aid. Playground equipment is in good condition.
The rooms are equipped with varied age appropriate materials and equipment. Facility will provide Breakfast and PM snack with lunch being brought home. Drinking water is provided inside and out via way of containers and cups/water bottles. Facility has a hard wired fire/smoke/carbon monoxide detector that is combined and facility knows how to test the system.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: DAVIS STREET COMMUNITY CENTER
FACILITY NUMBER: 013415253
VISIT DATE: 08/05/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
This facility provides Incidental Medical Services - IMS. Currently no children are in care that require those services. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly

All licensing required documents are posted. Zero Tolerance policies were explained. Notice of Site Visit form was provided and posted. The center was found to be clean, safe, sanitary and in good repair. There were no deficiencies cited during this visit.

A license for 60 school aged children operating out of 2 classrooms will be issued once the following is obtained:
- approval of the fire clearance

An exit interview was conducted was conducted with, Trish Murillo.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2