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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010212693
Report Date: 09/03/2019
Date Signed: 09/03/2019 02:55:15 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:ADVENTURE TIME - INDEPENDENTFACILITY NUMBER:
010212693
ADMINISTRATOR:MACIAS, LUCYFACILITY TYPE:
840
ADDRESS:21201 INDEPENDENT SCHOOL ROADTELEPHONE:
(510) 733-9134
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94552
CAPACITY:150CENSUS: 35DATE:
09/03/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Lucy MaciasTIME COMPLETED:
03:30 PM
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On 09/03/19, LPA Briana Plumboy met with Director Lucy Macias for an unannounced random inspection. The center and playground were toured to conduct a Health and Safety inspection. Present for the inspection was 35 school age children and 13 fingerprint clear and associated staff.

LPA Plumboy toured the facility with Director Lucy Macias. The center consists of two portables and the multipurpose room which is safe, clean and in good repair during today's inspection. There is adequate storage for children's belongings. There is adequate furniture, toys and activities, which are age appropriate and in good condition during today's inspection. The heating and lighting is adequate. There is drinking water readily available to children. The center uses the school bathrooms. There is a separate bathroom for boys and girls. All toilets flush properly, and there is running water, soap, and paper towels available for children to wash and dry their hands. There is a separate bathroom for staff. There are no bodies of water, or free standing water, accessible to children. The food preparation area is clean, free from hazards and adequately equipped. There is a menu posted, and there are no cleaning supplies stored with food. The center serves am snack during the morning program, and pm snack during the afternoon program. The manufactures sign on the playground states the equipment is for ages 5 through 12. All required documents are posted for public review. The center is in compliance with the sign in and out procedure. Disaster drills are being conducted at least once every 6 months. The center is equipped with a fully stocked first aid Kit, working telephone, carbon monoxide detector, pull down fire alarm and several fully charged fire extinguishers. The center is providing 1% milk to children in care.
All staff have been fingerprint cleared and associated to this center. All staff have provided proof of immunization against pertussis and measles, and provided a note declining the influenza immunization. At least one opening/closing staff member has a current CPR/First Aid certificate. See 809-C for continuance
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2019
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 2
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: ADVENTURE TIME - INDEPENDENT
FACILITY NUMBER: 010212693
VISIT DATE: 09/03/2019
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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

California Law requires Child Care Centers to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.


For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list

Director was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates.



Licensee is reminded that ALL Staff must be fingerprint cleared prior to being in the presence of children in care, or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident.

There are no deficiencies cited. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2019
LIC809 (FAS) - (06/04)
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