Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211796
Report Date: 03/18/2016
Date Signed 03/18/2016 05:12:03 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: 49DATE:
03/18/2016
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Jerre WilliamsTIME COMPLETED:
05:20 PM
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Licensing Program Analyst L. Dyer met with Jerre Williams for an unannounced Case Management - Other/ Plan of Correction Visit to review items cited on annual/random visit on 11/16/15.

During a previous inspection, the following were cited:

1. Center needed additional individual storage spaces.
2. Children enrolled needed forms signed.
3. Children enrolled did not have complete records.

The deficiencies listed above have been corrected as follows:

1a. Additional storage spaces have been provided. A waiver was also requested and approved.
2a. Forms were signed.
3a. Records have been completed.

See cleared POC dated 3/18/16.

Today no deficiencies were cited. Exit interview conducted. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. 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: 03/18/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2016
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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