Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211796
Report Date: 10/19/2015
Date Signed 10/20/2015 08:38:24 AM

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: 72DATE:
10/19/2015
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:29 PM
MET WITH:Jerre WilliamsTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst Lisa Dyer met with Jerre Williams for an unannounced Plan of Correction Visit to review items cited on annual/random visit on 9/09/15.

During a previous inspection, the following was cited:

1. Center does not have an adequate number of individual storage spaces.
(Center now has 80 storage areas.)
2. Children did not have the signed Personal Rights document in file for all children.
3. Children did not have complete records.

The deficiencies listed above have not been corrected and will be cited again today. Center has attempted to clear the citation but the citation has not adequately been cleared. Civil penalties will be assessed if the deficiencies are not cleared by the next due date.

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: 10/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2015
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: 10/19/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2015
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 DOES NOT HAVE ENOUGH INDIVIDUAL STORAGE SPACES.
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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
11/16/2015
Section Cited
.
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101223(b)(1)(A)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: THERE ARE CHILDREN WHO NEED FORMS SIGNED.
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Director will obtain signed Personal Rights Forms for all children in care.
Type B
11/16/2015
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: CHILDREN IN CARE DO NOT HAVE COMPLETE RECORDS.
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Director will review each child's record and verify that all forms are completed for all children 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: 10/19/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2015
LIC809 (FAS) - (06/04)
Page: 2 of 2