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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417913
Report Date: 11/16/2022
Date Signed: 11/16/2022 02:57:27 PM

Document Has Been Signed on 11/16/2022 02:57 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:WILSON, DONNAFACILITY NUMBER:
013417913
ADMINISTRATOR:WILSON, DONNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 909-4750
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
11/16/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:17 PM
MET WITH:Donna WilsonTIME COMPLETED:
03:55 PM
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Licensing Program Analyst Sidney Cortez met with licensee Donna Wilson for an announced case management visit. Licensee has been in inactive status, and wants to re-open. She needed guidance on re-opening, and covid 19 safety protocol refresher, and document/forms assistance.

LPA Cortez advised that she needed to retake First Aid and CPR Training for it has been expired. In addition Mandated Reporter needs to be taken for it has expired as well. She plans to use an assitant that needs to be fingerprinted as well.

It was also advised, and reviewed with the licensee that she understands Safe Sleep Procedure.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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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