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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010206037
Report Date: 07/23/2019
Date Signed: 07/23/2019 01:39:54 PM

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:OUSD - BELLA VISTAFACILITY NUMBER:
010206037
ADMINISTRATOR:ASENSIOSMENDOZA, OFELIAFACILITY TYPE:
850
ADDRESS:2410- 10TH AVENUETELEPHONE:
(510) 879-1657
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:64CENSUS: 23DATE:
07/23/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Shanna Birkholz-VasquezTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst Caroline Colson met with Shanna Birkholz-Vasquez, site administrator for an unannounced random annual inspection at 10:00 AM. A health and safety inspection was conducted. There are five bungalows which include four classrooms and one kitchen/lounge. During the summer break, there are only three (3) classroom being used. Two children's records were reviewed by the LPA and the licensee on 7/23/19 at 11:55 AM. C1 and C2 have immunization records on the California School Immunization Form. The Licensee stated to the analyst that there are no additional records available in the facility. Present were 22 preschool children and 7 staff members including site administrator. CLASSROOMS: The classrooms are equipped with tables, furniture and other materials for the children. The equipment is age appropriate and in good repair. There is adequate heating, ventilation and lighting. Drinking water is available inside and outside the center. There is a working telephone on site. There is proper individual storage space for each child. There are cots and individual storage bags for the blankets/sheets during nap time. There are bathrooms for staff and children. The sign in/sign out sheets were reviewed to verify census and signatures. The isolation area for sick children is the couch in the corner of the room. BATHROOMS AND TOILETING AREAS: Toilets and faucets work properly. The children are able to reach the sinks and toilets. Toilet paper, soap, and paper towels are all available. The school provides a breakfast, lunch and a snack. FOOD SERVICE: Food was inspected for freshness and quality. Meals are prepared off site by the School District. The State Preschool Program is only open for three hours and receives one meal during the day. Cleaning supplies are stored separately from food. OUTDOOR PLAY AREA: There are age appropriate toys and materials. HEALTH RELATED SERVICES: Site Administrator states that there are medications stored at the center. Medications are located in the classroom and stored in a locked cabinet. Earthquake emergency items are available. The first aid kit is complete and available.

Please See LIC 809 C for additional information
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: OUSD - BELLA VISTA
FACILITY NUMBER: 010206037
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2019
Section Cited
CCR
101220.1(g)
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Immuinizations
The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled. C1 and C2 don't have immunization records on the blue cards.
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By POC Due Date, Licensee will provide copies of C1 and C2 immunization records on the blue cards.
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This requirement was not met as evidenced by document review and licensee interview. This poses a potential health and safety risk to the children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250.00 per violation and $100 per day until corrected.
Type B
08/23/2019
Section Cited
CCR
101239(m)(1)
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Fixtures, Furniture, Equipment and Supplies
The licensee shall provide a variety of age-appropriate equipment, toys and materials in good condition and in sufficient quantity to allow children present to fully participate in planned activities.
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By POC Due Date, Licensee will remove all debris.
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There are two wagons that have excessive rust. There is a box of sand that is uncovered and filled with debris. This requirement was not met as evidenced by document review and licensee interview. This poses a potential health and safety risk to the children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250.00 per violation and $100 per day until corrected.
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: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: OUSD - BELLA VISTA
FACILITY NUMBER: 010206037
VISIT DATE: 07/23/2019
NARRATIVE
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 RECORDS: Staff members and children's files were reviewed. Required forms were posted in an public accessible area. CPR and First Aid certificates are current and expire March 9, 2021. There is a 2A10BC fire extinguisher, hard wired smoke detectors and a working carbon monoxide detectors.

There are no bodies of water accessible to children. There are no firearms on the premises. Children are being visually supervised. All storage areas for poisons are locked. Pest Integrated Management and Mandated Reporting were discussed. The website is www.mandatedreporterca.com. The course is under AB 1207.

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: 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 childcareadvocatesprogram@dss.ca.gov is the email address for the applicant to sign up to receive PINS.

Licensee was asked to go to our website at www.ccld.ca.gov to ensure that she is informed of all new laws and regulations.

The attached type B deficiencies are cited today and must be corrected by the due date. An exit interview was conducted. Appeal rights were given and discussed. A site notice was posted.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2019
LIC809 (FAS) - (06/04)
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