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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
013423105
Report Date:
03/10/2023
Date Signed:
03/10/2023 04:15:30 PM
Document Has Been Signed on
03/10/2023 04:15 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 LITTLE SCHOOL
FACILITY NUMBER:
013423105
ADMINISTRATOR:
HOLLY GOLD
FACILITY TYPE:
850
ADDRESS:
1611 HOPKINS STREET
TELEPHONE:
(510) 900-2433
CITY:
BERKELEY
STATE:
CA
ZIP CODE:
94707
CAPACITY:
42
TOTAL ENROLLED CHILDREN:
42
CENSUS:
18
DATE:
03/10/2023
TYPE OF VISIT:
Case Management - Annual Continuation
UNANNOUNCED
TIME BEGAN:
12:55 PM
MET WITH:
Josselyn Recinos
TIME COMPLETED:
04:25 PM
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SUPERVISORS NAME
:
Mayla Mendoza
LICENSING EVALUATOR NAME
:
Melissa Domantay
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/10/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/10/2023
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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