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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010205830
Report Date: 05/10/2023
Date Signed: 05/10/2023 04:40:23 PM


Document Has Been Signed on 05/10/2023 04:40 PM - 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:AGNES MEMORIALFACILITY NUMBER:
010205830
ADMINISTRATOR:SANDRA PHELPSFACILITY TYPE:
850
ADDRESS:2372 INTERNATIONAL BLVDTELEPHONE:
(510) 533-1101
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:24CENSUS: 21DATE:
05/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sandra PhelpsTIME COMPLETED:
04:45 PM
NARRATIVE
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On 05/10/2023 at 09:00 AM Licensing Program Analyst (LPA) Diana Campos conducted an unannounced Annual Required Inspection at Agnes Memorial. LPA met with center Director, Sandra Phelps 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-Friday 6:00 AM-7:00 PM.

Center 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.

The physical plant was inspected. LPA toured the premises used for day care.
Indoor space: Facility operates in one classroom (the preschool classroom) at the Agnes Memorial Christian Academy building. LPA observed 1 teacher and 2 Teacher Aids with 21 children. Facility was observed to be out of compliance with teacher to children ratio requirement during LPA’s inspection.
The preschool is distinctly separate to the areas of the building used by children enrolled in the private school program located on site and preschool children do not commingle with children not enrolled in the preschool.
The classrooms, restrooms, food storage areas and spaces accessible to children were inspected. Disinfectants, cleaning solutions, poisons and other items that are dangerous to the health and safety of children were stored in places inaccessible to them. Storage areas for poisons were locked and medications were kept in a safe place inaccessible to children. Cabinets, drawers, and rooms used for storage were locked. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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: AGNES MEMORIAL
FACILITY NUMBER: 010205830
VISIT DATE: 05/10/2023
NARRATIVE
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Restrooms for children were observed, all toilets and hand washing sinks are in safe and sanitary operating condition. All floors were clean and safe. LPA observed Fire extinguisher, Smoke and Carbon Monoxide Detectors. All materials and surfaces accessible to children appeared to be toxic free. Menus were observed to be posted in a place visible by the child’s authorized representative. Per director, there are no firearms present or stored on the premises.

Outdoor Space: Outdoor playground was inspected and observed to be fenced. The play structure equipment was incomplete and observed to be in need of repair. Areas around and under high climbing equipment and slides need to be replaced with material that absorbs falls. There were no bodies of water observed. Drinking water is readily available to children during indoor and outdoor activities. Outdoor play area was placed off limits until repairs are complete, inspected and approved by Licensing.



File Review: Children sign in and out procedures and logs were not available for review during today's inspection. A sample of five Children's files and Staff files were taken for review. Director and 2 assistants have current CPR/First Aid certification which expires 08/2023 as well as proof of Mandated Reporter training which expires 4/21/2025.

Incidental Medical Services (IMS) policy was discussed. 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

See LIC 809-D. for deficiencies observed and cited from the California Code of Regulations, Title 22 during today's inspection.
LPA informed Director Sandra Phelps that this report dated 5/10/2023 documents 1 Type A citation Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care.

Also, LPA informed the Director to provide a copy of this licensing report dated 5/10/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the center Director Sandra Phelps.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 11 of 11
Document Has Been Signed on 05/10/2023 04:40 PM - 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: AGNES MEMORIAL
FACILITY NUMBER: 010205830

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101216.3(a)
Teacher-Child Ratio
(a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the facility did not comply with the section cited above in that 1 teacher and 2 teacher aids were supervising a total of 21 preschool children which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2023
Plan of Correction
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Director shall submit plan of action by the POC date on how she will bring facility back into compliance as of tomorrow morning and how facility will remain in ratio going forward. Director will submit a summary of understanding of the Teacher to child ratios.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 11


Document Has Been Signed on 05/10/2023 04:40 PM - 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: AGNES MEMORIAL
FACILITY NUMBER: 010205830

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(a)
Disaster and Mass Casualty Plan
(a) Each licensee shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in that a Disaster and Mass Casualty Plan could not be made available during today's inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Facility will submit a copy of the disaster and mass casualty plan by the POC date either via mail or email.
Type B
Section Cited
CCR
101238.2(d)
Outdoor Activity Space
(d) The surface of the outdoor activity space shall be maintained:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview), the licensee did not comply with the section cited above in that outdoor play area is not maintained LPA observed tears in the fence and missing parts to the play structure which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Facility shall submit a plan of action on how facility will repair/maintain outdoor play area for children in care. Outdoor area may not be used by day care children until repairs are complete and inspected by LPA.
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 JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
Page: 3 of 11


Document Has Been Signed on 05/10/2023 04:40 PM - 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: AGNES MEMORIAL
FACILITY NUMBER: 010205830

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in that sign in/out sheets were not made available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Facility shall submit to LPA a plan of action on how facility will remain in compliance with the children's sign in/out procedure going forward.
Type B
Section Cited
CCR
101227(a)(19)
Food Service
(19) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above in LPA observed mold spots on a package of flour stored in the refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Facility discarded the flour during inspection. Deficiency cleared today.
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 JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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