Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013411130
Report Date: 04/26/2017
Date Signed 04/26/2017 10:52:21 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 - JENSEN RANCHFACILITY NUMBER:
013411130
ADMINISTRATOR:LAZZARI, TIFFANYFACILITY TYPE:
840
ADDRESS:20001 CARSON LANETELEPHONE:
(510) 728-9933
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94552
CAPACITY:90CENSUS: 5DATE:
04/26/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Valerie Reed and Mimi AlbertTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Cherie Acosta met with teacher, Valerie Reed for an unannounced annual/random visit. When LPA arrived there was 1 fingerprint cleared teacher and 5 school aged children present. During LPA's visit the program supervisor Mimi Albert arrived at the facility. The facility is located in a portable at the far end of Jensen Ranch Elementary school. The center was toured for a health and safety inspection. The facility appears to be safe, sanitary and in good repair. All the cleaning products and medicines were inaccessible to the children. Furniture appears to be in good condition and free of hazards. The toilets and faucets are in working order. The food preparation area and storage areas are clean and in sanitary condition. All storage containers for solid waste have tight fitting covers. The facility provides both morning and afternoon snacks. A menu is posted and visible for review. Drinking water is available both indoors and outdoors. The facility has a carbon monoxide detector, charged fire extinguisher and first aid kit.

The children are using the school yard for outdoor activities. Outdoor activity space appear to be safe and free of hazards. The school play structure closest to the portable is used by the children. There is another play structure that is not used by the children and is currently off limits due to the school making repairs. Visual supervision is provided while children are playing. Climbing equipment is properly anchored to the ground with adequate and appropriate cushioning material to absorb falls. There is a shaded area provided for the children.

A physical census was taken of all children present and crossed referenced with the sign in and out sheets.

LPA reviewed children and staffs records. Opening and closing staff have current CPR and first aid training. All required forms are posted and visible for public review. Fire and disaster drills are being conducted at least every six months.

SUPERVISOR'S NAME: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie AcostaTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2017
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 - JENSEN RANCH
FACILITY NUMBER: 013411130
VISIT DATE: 04/26/2017
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This facility provides Incidental Medical Services-IMS. LPA reviewed the storage of medication and equipment and supplies, and reviewed children’s, personnel, and administrative records. LPA discussed the need to update the centers plan of operation to reflect IMS plan. Specifics on the plan can be found in the child care center evaluator manual (CCC EM) Policy 101173. The following information regarding ADA was provided to licensee…US DOJ toll free ADA Information Line (800) 514-0301 and the link to FAQ about child care and ADA http://www.ada.gov/childqanda.htm

There are no deficiencies cited during today's inspection
. Exit interview was conducted.
The program supervisor was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights.

Notice of Site visit was posted at the time of inspection, and must remain posted for 30 days.
SUPERVISOR'S NAME: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie AcostaTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2017
LIC809 (FAS) - (06/04)
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