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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407702
Report Date: 04/20/2022
Date Signed: 04/20/2022 03:34:21 PM

Document Has Been Signed on 04/20/2022 03:34 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:PACHECO, VALERIAFACILITY NUMBER:
073407702
ADMINISTRATOR:PACHECO, VALERIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 504-2114
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
04/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:VALERIA PACHECOTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Melissa Domantay and Nyeesha Blount arrived to the facility unannounced to conduct a Case Management and POC visit. Present during today's visit were 12 children (3 infants, 9 preschoolers).

LPAs performed a health & safety check. See 809-D for the TYPE B deficiency that is being cited on today's visit. An exit interview was conducted. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights.

Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians newly enrolled at the facility during the next 12 months.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Melissa Domantay
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2022
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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Document Has Been Signed on 04/20/2022 03:34 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/20/2022 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: PACHECO, VALERIA
FACILITY NUMBER: 073407702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/20/2022
Section Cited
CCR
102416.5(e)

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This requirement was not met as evidenced by observation. The are 3 infants 9 preschoolers present wirh licensee was present at the time of arrival. This poses a potential health and safety risk to children in care.
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Cleared by visit.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022


LIC809 (FAS) - (06/04)
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