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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010212693
Report Date: 09/22/2022
Date Signed: 09/23/2022 08:02:51 AM


Document Has Been Signed on 09/23/2022 08:02 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 STE 1102
OAKLAND, CA 94612



FACILITY NAME:ADVENTURE TIME - INDEPENDENTFACILITY NUMBER:
010212693
ADMINISTRATOR:BREWER, TAMMYFACILITY TYPE:
840
ADDRESS:21201 INDEPENDENT SCHOOL ROADTELEPHONE:
(510) 733-9134
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94552
CAPACITY:150CENSUS: 102DATE:
09/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Lucy MaciasTIME COMPLETED:
05:00 PM
NARRATIVE
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On 09/22/2022 at 11:30am, Licensing Program Analyst (LPA) Christina Uribe conducted an Unannounced Annual Required Inspection. LPA met with the director Lucy Macias, also present at the time of the inspection were 9 staff & 102 children. The facility is within ratio & capacity compliance today. LPA provided facility representative the Entrance Checklist (LIC 125). The facility was toured to conduct a Health and Safety inspection. The facility currently operates 7:00am-8:30am in the mornings before school and 11:30am-6:00pm in the afternoon after school, Monday-Friday in two classrooms on the Independent Elementary School campus..

Classrooms: All classrooms were inspected for age-appropriate furnishings, equipment, & adequate storage for children’s belongings. LPA observed the cleanliness of floors & surfaces, the presence of a fully functional carbon monoxide detector, smoke detector/fire alarms, and a fully charged 3A40BC fire extinguisher that is accessible throughout the facility. The center is equipped with a fully stocked first-aid kit and available in the classrooms.

Food Service Areas: All center provided food items are properly labeled & stored separately from cleaning supplies. Food prep area is clean, adequately equipped, & free from hazardous materials. Snack menu is posted one week in advance, available for review, & dated.

Bathrooms: Facility has separate staff and child designated bathrooms. Toilets and faucets are in safe and sanitary operating condition. The children are able to reach the sinks and toilets. Supplies are available to children. Bathrooms are a part of the school and maintained by the district employees.

Outdoor Play Area: There are no bodies of water, or free-standing water accessible to children. There are age appropriate toys and materials for the children. The playground outside is fenced and all equipment and surfaces are free from hazards.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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
VISIT DATE: 09/22/2022
NARRATIVE
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Records: All individuals subject to criminal record review have a clearance and have been associated to the facility. LPA reviewed 10 children’s files and 12 staff files. LPA reviewed the facility roster & personnel record. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Mandated Reporter certificates were reviewed. The center is in compliance with sign in and out procedure. Emergency Drills are recorded and performed at least every six months and most recently on 08/17/22. Per facility representative, there are no firearms on the premises. All required documents are posted in a publicly accessible area.

Health-Related Services: This facility does provide Incidental Medical Services (IMS). LPA inspected storage of medications and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations & Procedures for Child Care Centers sections 101173 & 101226. 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

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Effective August 1, 2003 California Law requires Child Care Licensees 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 to the regional office by phone and the written report, LIC 624, within 7 business days.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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
VISIT DATE: 09/22/2022
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Deficiencies & Advisory Notes issued during today's inspection:
  • Type B Violation: Two staff members did not have a mandated reporter training certificate & two others only had a certificate for the general training.
  • Technical Violation: Health Screening Report (LIC 503) needed for two staff members.
  • Technical Violation: Facility uses their own letterhead version of licensing forms, however, their substitute of the Identification & Emergency (LIC 700) form is missing a required field for the child's gender to be filled out by the parent. Substitution for licensing forms must include all of the same information that is on the official LIC form.
  • Technical Violation: Facility uses their own letterhead version of licensing forms, however, their Parent Agreement has a section which is a substitute for the Consent for Emergency Medical Treatment (LIC 627) form. This does not include a section for the parent to fill out any information for medication allergies that a child may have. Additionally, 5 children's files did not have this section filled out by the parent at all. Substitution for licensing forms must include all of the same information that is on the official LIC form.
  • Technical Violation: All medications must be in their original packaging with the prescription label. 2 child medications were not stored with their original packaging.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the director, Lucy Macias.

Page 3 of 3 ***End of Report***

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 09/23/2022 08:02 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 STE 1102
OAKLAND, CA 94612


FACILITY NAME: ADVENTURE TIME - INDEPENDENT
FACILITY NUMBER: 010212693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review & interview, the licensee did not comply with the section cited above as 4 staff members did not have a current Mandated Reporter certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Facility administrator will ensure that all staff members obtain a current certificate for the mandated reporter training specific for child care providers (AB 1207). Each staff member will be given an appropriate amount of time during their scheduled shift to complete this training. Certificates will be emailed to LPA Uribe for proof of correction no later than the due date of 10/21/2022. Email to christina.uribe@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Christina UribeTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
LIC809 (FAS) - (06/04)
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