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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010210219
Report Date: 12/18/2023
Date Signed: 12/18/2023 10:25:52 AM


Document Has Been Signed on 12/18/2023 10:25 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:GAN MAH TOV PRESCHOOLFACILITY NUMBER:
010210219
ADMINISTRATOR:BENCUYA, ANNAFACILITY TYPE:
850
ADDRESS:3778 PARK BOULEVARDTELEPHONE:
(949) 378-7167
CITY:OAKLANDSTATE: CAZIP CODE:
94610
CAPACITY:40CENSUS: DATE:
12/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Julia Neely TIME COMPLETED:
10:30 AM
NARRATIVE
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On 12/18/2023 at 9:15AM Licensing Program Analysts (LPAs), A. Curry and B. Crass conducted an unannounced inspection to follow up regarding a complaint at the facility. During interviews that were conducted for the complaint, it was revealed that multiple parents volunteer in the classroom. The director indicated she does not have a complete file for the parent volunteers (See 809D). The director was advised that all parents volunteers must have a complete file that includes, a good health statement, a Tuberculosis test that was performed not more than 1 year prior to initial presence in the facility, and proof of immunity for Mealses, and Pertussis.


Exit interview conducted, appeal rights were given, and report was reviewed with the Director, Julia Neely.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
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 12/18/2023 10:25 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: GAN MAH TOV PRESCHOOL
FACILITY NUMBER: 010210219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2024
Section Cited
HSC
1596.7995(c)

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§1596.7995 Employees or volunteers at day care center; immunization requirements; records; exemptions(c) The day care center shall maintain documentation of the required immunizations... in the person’s personnel record that is maintained by the day care center.
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By 01/18/2024 submit a written statement on how the facility will comply with the regulation.
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This requirement is not as evidence by:

Based on interviews the licensee did not comply with the section cited above by ensuring all parent volunteers have a complete file, which poses a potential risk to the health and safety of 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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
LIC809 (FAS) - (06/04)
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