Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211796
Report Date: 08/25/2015 12:00:00 AM
Date Signed 08/25/2015 05:54:19 PM

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:ADVENTURE TIME - CROCKER HIGHLANDSFACILITY NUMBER:
010211796
ADMINISTRATOR:WILLIAMS, JERREFACILITY TYPE:
840
ADDRESS:525 MIDCREST ROADTELEPHONE:
(510) 834-1578
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:120CENSUS: 64DATE:
08/25/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:37 PM
MET WITH:Jerre WilliamsTIME COMPLETED:
05:58 PM
NARRATIVE
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(3) LPA Lisa Dyer met with Jerre Williams for an annual/random inspection. Present are 64 children and 6 staff in this school age program. The children were in one portable. Sign-in/sign-out sheets list the time and parents' full signature. There is a working phone. The last fire/emergency drill was June, 2015. Director and Designation of Facility Responsibility is current.

The center is closing so this visit will be continued.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2015
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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