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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010212693
Report Date: 10/26/2020
Date Signed: 10/26/2020 04:04:14 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: 29DATE:
10/26/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:57 PM
MET WITH:Diamond PoweTIME COMPLETED:
04:30 PM
NARRATIVE
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On 10/26/20 at 1:57pm, Licensing Program Analyst (LPA) Briana Plumboy met with Diamond Powe to conducted an unannounced Case Management inspection. LPA Plumboy was at the facility for another purpose, which resulted in a case management inspection. Present for the inspection was 29 school age children and 6 staff.

Regulatory violations were observed during today's Case Management inspection. Therefore, citations were issued for the use of a classroom which is not approved nor licensed by CCLD, 4 staff are fingerprinted but not associated to the facility, and there is not a current roster readily available at the center. A technical violation was issued today due to reporting requirements because the Administrator failed to notify Community Care Licensing there was a new Director at the facility.

The attached Type A deficiency regarding criminal record clearance is being cited today. A civil penalty in the amount of $500 is being assessed for each staff who is not currently associated to the facility. The attached Type A deficiency is cited today. Upon receipt, licensee shall post for 30 days and provide copies of this licensing report to parent/guardians of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 Acknowledgement of Receipt of Licensing Reports should be signed by guardians and placed in each child’s file.

This entire report has been read to by LPA Plumboy. The staff is aware the signature on this report confirm receipt of these documents. LPA asked Ms.Diamond Powe if she had any questions pertaining to any aspects including, but not limited to, any part of this report and of the documents given. At this time it was stated there are no further questions at this time. At anytime she can reach out to LPA Plumboy or CCLD.



See (2)809-Ds and technical violation for deficiencies cited today. Appeal rights discussed and provided. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days along with a copy of this entire report. Exit interview conducted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: ADVENTURE TIME - INDEPENDENT
FACILITY NUMBER: 010212693
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2020
Section Cited

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101170(e)(2) 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 is not met as evidenced by record review. This poses an immediate risk to the health and safety of children in care.
TODAY AN IMMEDIATE CIVIL PENALTY OF $2000 IS ASSESSED BECAUSE 4 STAFF CLEARANCES ARE NOT ASSOCIATED TO THIS FACILITY. By 4 staff members fingerprints not being associated, it poses an immediate health and safety risk to children in care.
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$2,000 Civil Penalty assessed.
Lic.9224 shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months.

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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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2020
Section Cited

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Current roster of children provided care in facility required. Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian
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and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request. This requirement is not met based on interview and file review.The facility roster was not current, which poses a potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type B
11/06/2020
Section Cited

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101212(c) The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space. Such structural changes shall include, but not be limited to, room additions.
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Based on inspection, interview & record review. There is no documentation regarding the addition of classroom 36. Use of classroom 36 and it not being approved prior to its use poses a potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2020
LIC809 (FAS) - (06/04)
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