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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400419
Report Date: 03/17/2023
Date Signed: 03/20/2023 11:22:30 AM

Document Has Been Signed on 03/20/2023 11:22 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:WCCUSD - MONTALVIN C/O PRESCHOOL DEPARTMENTFACILITY NUMBER:
073400419
ADMINISTRATOR:ROMERO, VENESSAFACILITY TYPE:
850
ADDRESS:300 CHRISTINE DRIVETELEPHONE:
(510) 231-1405
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 17DATE:
03/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Derri PollackTIME COMPLETED:
04:00 PM
NARRATIVE
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On Friday, March 17, 2023 at 10:28 AM, Licensing Program Analyst (LPA) Caroline Colson met with Derri Pollack, Lead Teacher, for an unannounced case management inspection. There are 17 children with 3 staff members present. The purpose of the inspection was to conduct a follow-up on an unusual incident. 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: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2023
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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