Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416697
Report Date: 01/20/2017
Date Signed 01/20/2017 10:44:21 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:ALA COSTA CENTERFACILITY NUMBER:
013416697
ADMINISTRATOR:COFFIELD, TANYAFACILITY TYPE:
840
ADDRESS:3390 MALCOLM STREETTELEPHONE:
(510) 383-3200
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY:50CENSUS: 0DATE:
01/20/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Michael PereiraTIME COMPLETED:
10:45 AM
NARRATIVE
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LPA Dayna Collier met with Executive Director Michael Pereira for a case management visit as a result of receiving an unusual incident report. An incident occurred when staff took clients on an outing to a nearby shopping mall. While a small group consisting of 2 staff and 3 clients ate at the food court, one staff member took 3 clients into the Target store to shop. One client bolted from the food court in an attempt to find the staff member inside the store. A staff member intervened which initially caused the client to stop. However, the client bolted a second time. As the staff member attempted to follow the running client, she lost sight of him as he turned the corner of the hallway. The staff member assumed that the client entered the Target so she returned to the food court to call the staff member inside of the store. The staff member inside of the store received the call and located the client inside of the store in the book section. Based on the timeline that staff provided to the director, it appears that the client was without visual supervision for 3-4 minutes.

The attached type A deficiency is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

An exit interview was conducted and the facility report was discussed and reviewed with the Director. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and the signature on this form acknowledges receipt of these rights.

A site visit notice will be posted by the Director.
SUPERVISOR'S NAME: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: 510-725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2017
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: ALA COSTA CENTER
FACILITY NUMBER: 013416697
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2017
Section Cited
101229(a)(1)
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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).
In accordance with the California Health and Safety Code Section 1596.99(c), you are hereby notified that an immediate $150 civil penalty per violation, followed by $150 per day per violation will be assessed until corrected.
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POC: By 1/27/17, a written plan of action will be sent to Licensing detailing steps staff will take to ensure clients are visually supervised at all times.
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A CLIENT BOLTED FROM THE GROUP, ENTERING A STORE ALONE UNTIL A STAFF MEMBER LOCATED HIM.
A LIC 421C FORM WAS PROVIDED TO THE DIRECTOR.
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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: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: 510-725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 01/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2017
LIC809 (FAS) - (06/04)
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