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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010209547
Report Date: 09/22/2023
Date Signed: 09/22/2023 11:37:29 AM


Document Has Been Signed on 09/22/2023 11:37 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:BETH SHOLOM PRESCHOOLFACILITY NUMBER:
010209547
ADMINISTRATOR:CHASE, AMANDAFACILITY TYPE:
850
ADDRESS:642 DOLORES AVENUETELEPHONE:
(510) 357-8505
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:49CENSUS: 28DATE:
09/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amanda ChaseTIME COMPLETED:
12:00 PM
NARRATIVE
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On 09/22/2023 at 9:30am, Licensing Program Analyst (LPA) Christina Uribe conducted a Case Management visit to the facility and met with site director, Amanda Chase. Also present at the time of today's visit are 28 children and 5 staff. The purpose of today's visit is to address an unusual incident report submitted by the facility regarding a lack of supervision incident with a day care child.

On 08/31/2023 a day care child was left unattended in the facility bathroom. The classroom staff noticed that the child was not in the classroom after the transition time from washing hands and using the bathroom for the whole class. The teachers notified the site director and began looking for the child. Within a few minutes of beginning to look, the site director went into the bathroom and called the child's name and he responded. He had been hiding in one of the bathroom stalls as he was embarrassed from having had an potty accident.
The site director assigned a staff member to help clean and change the child into new clothes while the site director called the child's parents to notify them of the incident.

Due to the lack of supervision, the facility is being issued a Type A Violation today and a $500.00 civil penalty is also being assessed today. LPA Uribe informed the director, Alice Chase, that this report dated 09/22/2023 documents one 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 Uribe informed the site director to provide a copy of this licensing report dated 09/22/2023 that documents any Type A citation 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.

Notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in the immediate civil penalty of $100. Appeal rights were also given. Exit interview and report was reviewed with the site director, Amanda Chase.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
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 2


Document Has Been Signed on 09/22/2023 11:37 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: BETH SHOLOM PRESCHOOL
FACILITY NUMBER: 010209547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/26/2023
Section Cited
CCR
101229(a)(1)

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101229(a)(1) - Responsibility for Providing Care & Supervision: No child(ren) shall be left without the supervision of a teacher at any time. Supervision includes visual supervision.
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Staff will watch the "Supervising Children in Child Care Centers" on the CCLD website. Director will create a written statement stating new protocols in place to follow in order to prevent a child in care being left unaccounted and without supervision. Director will have all staff sign and date the written statement
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This requirement was not met as evidenced by:

One child was left in the facilitiy bathroom unattended & without supervision which poses an immediate risk to the health, safety, or personal rights to persons in care.
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acknowledging that they have watched the assigned training video and understand their responsibility to provide supervision to children at all times and will implement the new procotols put in place. Director will email this signed statement to LPA Uribe now later than 09/26/23 at 2pm.

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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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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