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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211122
Report Date: 01/16/2020
Date Signed: 01/16/2020 01:36:34 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:MODEL SCHOOL COMPREHENSIVE HUMANISTIC LEARNING CTRFACILITY NUMBER:
010211122
ADMINISTRATOR:MANTE, DAISY L.FACILITY TYPE:
830
ADDRESS:2330 PRINCE STREETTELEPHONE:
(510) 549-2711
CITY:BERKELEYSTATE: CAZIP CODE:
94705
CAPACITY:20CENSUS: 13DATE:
01/16/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Director Daisy L ManteTIME COMPLETED:
02:00 PM
NARRATIVE
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On 01/16/2020, Licensing Program Analyst (LPA) Brittany Newton made an unannounced visit for the purpose of following up on an Incident Report submitted to CCL 12/19/2019. LPA Newton was met by the Director Daisy L Mante. Present for the inspection was 13 infants with four staff members.
LPA toured the facility, obtained documentation and conducted interviews with the Director and the staff member involved.

The incident was regarding a staff member drinking hot tea while working with the infants. The tea was placed on the ground and an infant who was on the floor playing, knocked it over. The tea spilled on the infants foot causing a blister. Immediate medical attention was not needed, but, today, LPA Newton observed a mark on the infants foot from the incident. A picture was taken for documentation purposes.


A deficiency was cited at this visit. See LIC 809D for deficiency cited.

Exit interview conducted, appeal rights provided, and a copy of this report was left with director Daisy Mante. A notice of site visit was given and facility is reminded it shall remain posted for 30 days.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Brittany NewtonTELEPHONE: (510) 622-2594
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020
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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: MODEL SCHOOL COMPREHENSIVE HUMANISTIC LEARNING CTR
FACILITY NUMBER: 010211122
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2020
Section Cited

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Personal Rights. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
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Based upon interviews conducted and documentation obtained, a staff member drank hot tea and placed it on the floor while working with infants. The tea spilled over and landed on an infants foot which poses a potential Health, Safety, or Personal Rights Risk to children in care.
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Failure to correct will result in a $100.00 per day civil penalty until corrected. Repeat
Violation are $250.00 per violation and $100.00 per day until corrected.

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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) 622-2602
LICENSING EVALUATOR NAME: Brittany NewtonTELEPHONE: (510) 622-2594
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2020
LIC809 (FAS) - (06/04)
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