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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010205830
Report Date: 09/26/2023
Date Signed: 09/26/2023 01:06:44 PM


Document Has Been Signed on 09/26/2023 01:06 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: 14DATE:
09/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:54 AM
MET WITH:Sandra PhelpsTIME COMPLETED:
01:10 PM
NARRATIVE
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On 9/26/2023 Licensing Program Analyst (LPA) Diana Campos conducted an unannounced case management visit. LPA met with Center Director Sandra Phelps to investigate a complaint. During the complaint investigation it was discovered that one staff present today was not associated to facility and did not have eligible criminal record clearance due to an incomplete application.
While conducting a children's file review, it was discovered that at least 7 children are missing an Identification and Emergency Information form (LIC700).

See 809-D for deficiencies cited during today's visit.

LPA informed Director Sandra Phelps that this report dated 9/26/2023 document(s) 1 Type A citation which shall be posted for 30 consecutive days as there is 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 9/26/2023 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.

Exit interview conducted with Director Sandra Phelps.


Notice of Site visit was provided and must remain posted for 30 days.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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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Document Has Been Signed on 09/26/2023 01:06 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: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2023
Section Cited
CCR
101216(i)(1)(2)(3)

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101216(i)(1)(2)(3) Prior to employment or initial presence in the child care center, all employees and volunteers subject to a criminal record review shall: (1)Obtain a California clearance or a criminal record exemption as required by law or Department regulations or
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Director will submit to licensing proof of live scan receipt and confirmation of association to facility before staff can return.
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(2)Request a transfer of a criminal record clearance as specified in Section... (3)Request and be approved for a transfer of a criminal record exemption, as specified in Section 101170.1(r)... This requirement was not met as evidenced by: One staff assisting with day care children was not associated to facility or have current clearance this poses an immediate health and safety risk to persons in care.
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Type B
10/16/2023
Section Cited
CCR101221(a)(b)(5)

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Childs Records. The licensee shall maintain, in each child’s record, a copy of the emergency information card required in Section 101221(a)(b)(5)...
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Facility will submit to Licensing completed and signed copies of this form (LIC700) for all 7 Children by the POC due date.
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This requirement was not met as evidenced by record review: licensee did not have an emergency information card for 7 out of 14 children. This poses a potential Health and Safety Risk to children in care.
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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: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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