010200592-10-24-2022-02-CC-MSUN-CKHNXR-20221024105135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 010200592
Report Date: 10/24/2022
Date Signed: 10/24/2022 10:51:42 AM

Document Has Been Signed on 10/24/2022 10:51 AM - It Cannot Be Edited

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:	SEQUOIA NURSERY SCHOOL		FACILITY NUMBER:	010200592
ADMINISTRATOR:	LORI FULLER		FACILITY TYPE:	850
ADDRESS:	2666 MOUNTAIN BOULEVARD		TELEPHONE:	(510) 531-8853
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94611
CAPACITY:	40	CENSUS: 17	DATE:	10/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Lori Fuller		TIME COMPLETED:	10:51 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/24/22 at 9:20 AM Licensing Program Analyst (LPA) Michelle Sutton conducted an unannounced 5-Year Annual Inspection at Sequoia Nursery School. LPA met with Director, Lori Fuller and explained the purpose of today's inspection. LPA was granted inspection authority to enter the facility. The facility was toured to conduct a Health and Safety Inspection. Facility's operating days and hours are Monday to Friday 8:30 AM-12:30PM. Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. LPA toured the premises with the Director. The physical plant of the facility was inspected: Facility operates In one main room. Facility was observed to be in compliance with teacher to children ratio requirement for a Parent Cooperative Center during LPA’s inspection. Disinfectants, cleaning solutions, poisons and other items that are dangerous to the health and safety of children were stored in places inaccessible to them. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. Restrooms for children were observed, all toilets, hand washing are safe and sanitary operating condition. All floors were clean and safe. Foods and beverages were stored safely. Food storage area were clean, free of litter, rubbish, and free of rodents and other vermin. LPA observed Fire extinguisher, Smoke and Carbon Monoxide Detectors through the Main room of the facility. All materials and surfaces accessible to children appeared to be toxic free.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle Sutton	TELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

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: SEQUOIA NURSERY SCHOOL	FACILITY NUMBER: 010200592
	VISIT DATE: 10/24/2022

NARRATIVE

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Outdoor Space: Outdoor playground was inspected and observed to be safe. The play equipment was maintained in good condition and free of hazards. Surface of the outdoor activity space was in safe condition and free of hazards. Areas around and under high climbing equipment and slides were cushioned with material that absorbs falls. There were no bodies of water observed. Drinking water is readily available to children during indoor and outdoor activities.

File Review: Children sign in and out procedures and logs were reviewed. A sample of five (5) Children's files and two (2) Staff files was taken for review.

This facility provides Incidental Medical Services- IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the director Lori Fuller.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle Sutton	TELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/24/2022 10:51 AM - It Cannot Be Edited

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: SEQUOIA NURSERY SCHOOL	FACILITY NUMBER: 010200592
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101174(d)

Disaster and Mass Casualty Plan

(d) Disaster drills shall be conducted at least every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above due to the facility has not conducted any diaster drills this year which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/07/2022
	Plan of Correction
1 2 3 4	By POC due date the facility shall conduct a earthquake and fire drill and submit proof to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle Sutton	TELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3