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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
013420965
Report Date:
07/11/2024
Date Signed:
07/11/2024 03:04:16 PM
Document Has Been Signed on
07/11/2024 03:04 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:
BERKELEY YMCA HEAD START - SOUTH YMCA
FACILITY NUMBER:
013420965
ADMINISTRATOR/
DIRECTOR:
DORIAN BURNLEY
FACILITY TYPE:
830
ADDRESS:
2901 CALIFORNIA ST
TELEPHONE:
(510) 649-7988
CITY:
BERKELEY
STATE:
CA
ZIP CODE:
94703
CAPACITY:
42
TOTAL ENROLLED CHILDREN:
17
CENSUS:
10
DATE:
07/11/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:
Dorian Burnley
TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Cherie Acosta and Dealia Frison conducted an unannounced case management visit in regards to a self reported incident. LPAs met with Director Dorian Burnley.
During the visit LPAs toured the facility for a health and safety inspection and conducted interview.
There are no deficiencies cited during today's inspection.
Exit interview and report reviewed with Dorian Burnley.
Notice of Site Visit was provided and must be posted for 30 days.
SUPERVISORS NAME
:
Sherelle Johnson
LICENSING EVALUATOR NAME
:
Cherie Acosta
LICENSING EVALUATOR SIGNATURE
:
DATE:
07/11/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
07/11/2024
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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