010212693-12-15-2020-52-CC-WNOA-BWJPZK-20201222104538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 010212693
Report Date: 12/15/2020
Date Signed: 12/15/2020 11:00:12 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/21/2020 and conducted by Evaluator Briana Plumboy

COMPLAINT CONTROL NUMBER: 52-CC-20201021135907

FACILITY NAME:	ADVENTURE TIME - INDEPENDENT		FACILITY NUMBER:	010212693
ADMINISTRATOR:	MACIAS, LUCY		FACILITY TYPE:	840
ADDRESS:	21201 INDEPENDENT SCHOOL ROAD		TELEPHONE:	(510) 733-9134
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94552
CAPACITY:	150	CENSUS: 15	DATE:	12/15/2020
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mimi Albert		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal Rights- Child was left in soiled clothing for a long period of time

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/15/20, Licensing Program Analyst (LPA) Plumboy met with Executive Director Mimi Albert for the purpose of an unannounced complaint investigation regarding the above allegation. Present during the inspection was 4 staff and 15 children in care.

Based on interviews conducted, the allegation a child was left in soiled clothing for a long period of time is unsubstantiated. The reporting party alleged her son was left in soilded clothing at the center and stated she discovered this once she was home. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED.
A notice of site visit was given and must remain posted for 30 days.
Appeal Rights were given and discussed. An exit interview was conducted.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 2