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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420548
Report Date: 12/09/2021
Date Signed: 12/09/2021 04:40:58 PM

Document Has Been Signed on 12/09/2021 04:40 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:UCB - UNIVERSITY VILLAGE ECEPFACILITY NUMBER:
013420548
ADMINISTRATOR:KRISTEN BURMESTERFACILITY TYPE:
850
ADDRESS:1123 JACKSON STTELEPHONE:
(510) 642-1827
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 10DATE:
12/09/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Laureana MedranoTIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Caroline Colson met with Laureana Medrano, Teacher, and Darrell Witacre, Interim Center Director for an unannounced case management inspection at 3:10 PM. There are 10 preschoolers and 4 teachers present. The purpose of the inspection was the result of receiving an unusual incident report. An interview was conducted.

There were no deficiencies cited during this inspection.

An exit interview was conducted. Appeal Rights were given and discussed.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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