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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010209547
Report Date: 10/30/2019
Date Signed: 10/30/2019 12:03:35 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:BETH SHOLOM PRESCHOOLFACILITY NUMBER:
010209547
ADMINISTRATOR:DANEK, SUSAN LFACILITY TYPE:
850
ADDRESS:642 DOLORES AVENUETELEPHONE:
(510) 357-8505
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:49CENSUS: 37DATE:
10/30/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Susan DanekTIME COMPLETED:
12:15 PM
NARRATIVE
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LPA Dayna Collier met with Center Director Susan Danek for a case management inspection. There were 9 staff members supervising 37 children in care.
A review of staff records on 10/30/19 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions except Mabel Tafolla whose clearances are not associated to this facility.

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 report was discussed. 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 was posted by Director.
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2019
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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: BETH SHOLOM PRESCHOOL
FACILITY NUMBER: 010209547
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2019
Section Cited

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101170 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 101170(f).
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This requirement was not met as evidenced by record review and poses an immediate risk to children in care.
TODAY AN IMMEDIATE CIVIL PENALTY OF $500 IS ASSESSED BECAUSE MABEL TAFOLLA'S CLEARANCES ARE NOT ASSOCIATED TO THIS FACILITY.
AN LIC 421BG IS GIVEN TO DIR.
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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: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2019
LIC809 (FAS) - (06/04)
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