Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211796
Report Date: 09/09/2015 12:00:00 AM
Date Signed 09/09/2015 04:38:19 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: 107DATE:
09/09/2015
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jerre WilliamsTIME COMPLETED:
04:50 PM
NARRATIVE
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This is a continuation of the annual/random visit for this facility. There are 8 fingerprint cleared teachers and 107 school-age children present at the start of the inspection.

Proper posting requirements were met with the exception of the Car Safety Seat Law and Earthquake Preparedness - they were given to the director to post. Classroom furniture is in good condition. There are toys, books, games and educational supplies available. Floors were clean and safe. There is adequate heating, ventilation, and lighting. Bathroom toilets and sinks are working properly. There were adequate bathroom supplies. Kitchen area (including storage areas for food) was clean. No insects or pests were seen. A sample of food product was examined for freshness and expiration dates. The center supplies snacks only. Menus were posted. Inside, there are 32 cubbies. There is drinking water available at all times inside the center through dispensers and paper cups, and outside with a fountain. Director stated that there were no bodies of water or firearms on the premises. There is a first aid kit located in a cabinet near the front window. Emergency earthquake supplies are located under the table inside of the portable.
Cleaning supplies are inaccessible to children, placed in a high cabinet. Incidental Medical Services were discussed with the director. The director is not providing IMS at this time. Licensee will submit a plan of operation in the future if they provide any IMS services to a child in care. Outside play area is safe and free of hazards. There were a variety of toys and play materials. The area around the climbing playground equipment is cushioned with material that absorbs a fall. There is an outside shaded area behind the building.
Children's files (sample) were examined. Admission agreement is available for review. Staff records contain a health screening assessment. The director has CPR/First Aid current until 3/1/16. All individuals subject to a criminal record review have obtained clearance or a criminal record exemption.
See LIC 809-D for citations.
Exit interview conducted. Appeal rights and AB 633 Fact Sheet was discussed and given. This report must be kept available for public review for 3 years, and notice of site visit must be posted for 30 days.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2015
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 HIGHLANDS
FACILITY NUMBER: 010211796
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2015
Section Cited
101238.4(a)
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Storage Space. The licensee shall ensure that each child has an individual permanent or portable storage space for his/her clothing, personal belongings and/or bedding. OBSERVED: CENTER LICENSED FOR 120 HAS 32 INDIVIDUAL STORAGE SPACES. (106 CHILDREN PRESENT TODAY). OTHER ITEMS ARE PLACED OUTSIDE.
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Licensee will obtain additional storage space for children in care so that each child has an individual permanent or portable storage space.
Type B
10/12/2015
Section Cited
101223(b)(1)(A)
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Personal Rights. Each authorized representative shall sign and date the acknowledgement-of-receipt statement at the bottom of the LIC 613A (9/96) and the document shall be kept in the child’s file. OBSERVED: CHILD #1, 2, 4, 5, 6, AND 7 DO NOT HAVE THE SIGNED PERSONAL RIGHTS DOCUMENT IN FILE.
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Director will obtain signed Personal Rights Forms for all children in care.
Type B
10/12/2015
Section Cited
101221(a)
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Child’s Records. The licensee shall ensure that there are separate, complete and current records kept for each child attending the child care center. OBSERVED: OBSERVED: CHILD #1, 2, 4, 5, 6, AND 7 DO NOT HAVE COMPLETE RECORDS.
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Director will review each child's record and verify that all forms are completed for each child in care.
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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: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2015
LIC809 (FAS) - (06/04)
Page: 2 of 2