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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010212693
Report Date: 09/08/2023
Date Signed: 09/08/2023 05:52:26 PM


Document Has Been Signed on 09/08/2023 05:52 PM - 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: 89DATE:
09/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Lucy MaciasTIME COMPLETED:
05:50 PM
NARRATIVE
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On 9/8/2023 at 1:05pm Licensing Program Analyst (LPA) Morgan Pringle conducted an Unannounced Annual Inspection at the facility. During LPA's inspection Director Lucy Macias informed LPA that last week on 8/31/2023 a child fell off of the metal "dome" outside and sustained a hairline fracture to their arm. Director stated that the child fell off of the structure and braced themselves with their wrist which caused the injury. LPA spoke with facility staff who stated the child walked inside and notified staff they had fallen off of the dome and onto their wrist. An ice pack was then applied and the child's parent walked in immediately after to pick their child up.

The facility was notified the child sustained a fractured wrist on Friday 9/1/2023. Through interview and record review it was found that the facility did not report to Community Care Licensing that a child had sustained an injury while in care. It was determined that none of the staff saw the child fall off of the structure as well as the child informed staff herself of what had happened.

Deficiencies Cited
· Lack of supervision resulting in child sustaining injury while in care
· Failure to report incident with 24 hours of being notified of the incident


LPA Pringle informed Director that this report dated 9/8/2023 document(s) 1 Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
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: 09/08/2023
NARRATIVE
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Also, LPA Pringle informed the Director to provide a copy of this licensing report dated 9/8/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

An immediate civil penalty of $500.00 is being assessed for the lack of supervision that resulted in a child sustaining an injury while in care.

Licensee was reminded that California law requires facilities to report unusual incidents and/or injuries to children in care, to the child's parents, and to the Department within 24 hours by phone, fax, or email. Within seven (7) days from the incident, facilities must submit the Unusual Incident/Injury form (LIC 624) to the Department.

A notice of site visit was given and must remain posted for 30 days.



Exit interview conducted and report was reviewed with the Director Lucy Macias.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2023 05:52 PM - 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: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2023
Section Cited
CCR
101229(a)(1)

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(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation. This requirement is not met as evidenced by:
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By 9/13/2023 Director will submit a written plan to LPA Pringle on how the facility staff will ensure complete supervision of all children in care at all times while outside. Director will give this to all staff and have them sign the plan. Director will submit signed plans to LPA Pringle.
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Child sustained a fractured wrist while in care. Injury was not seen by any staff member present that day. This poses an immediate risk to the health and safety of children in care.
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Type B
09/13/2023
Section Cited
CCR101212(d)(1)(B)

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(d) Upon the occurrence... a report shall be made to the Department...wthin the Department's next working day and during its normal business hours. In addition, a written report...shall be submitted to the Department within seven days...(1) Events reported shall include the following:
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Director will also watch the "Reporting Requirement" video on the CCLD website. Director will submit a statement stating the correct reporting requirement for Child Care Centers. Statment will be sent to LPA Pringle by 9/13/2023.
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(B) Any injury to any child that requires medical treatment. This requirement was not met as evidenced by: A child sustained a fractured wrist witle in care and the incident was not reported to the Department.
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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: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
LIC809 (FAS) - (06/04)
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