010213705-10-22-2021-52-CC-MOTI-C82QKD-20211022121409

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 010213705
Report Date: 10/22/2021
Date Signed: 10/22/2021 12:14:19 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:	GAN SAMEACH NURSERY SCHOOL		FACILITY NUMBER:	010213705
ADMINISTRATOR:	JACOB, ANNIE		FACILITY TYPE:	850
ADDRESS:	42000 PASEO PADRE PARKWAY		TELEPHONE:	(510) 651-5833
CITY:	FREMONT	STATE: CA	ZIP CODE:	94539
CAPACITY:	22	CENSUS: 8	DATE:	10/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Annie Jacob		TIME COMPLETED:	12:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Melanie Otsuji arrived to the facility unannounced on today's date, 10/22/2021, to conduct a REQUIRED 1 YEAR inspection. LPA was met by Director Annie Jacob. Present during today's visit was 3 staff members and 8 preschool aged children. LPA conducted a health & safety inspection inside and outside. LPA observed disinfectants, cleaning solutions and other items which are dangerous to children are kept inaccessible to children in care. Furniture and playground equipment are in good condition, free of sharp, loose or pointed parts. Surface areas of outdoor activity space are maintained free of hazards. Toilets and hand washing facilities are in safe and sanitary operating condition. Kitchen area was kept clean, free of litter. Food was observed to be protected against contamination. All storage containers for solid waste had tight-fitting covers that were kept on and in good repair. Drinking water is readily available both inside and outside. The areas around/under high climbing equipment is cushioned with material that absorbs a fall. Carbon Monoxide detector, smoke detector and fire extinguisher were observed to be in operable condition. On today's date, LPA reviewed (3) personnel files and (8) children's files. Record review indicates that all staff present during today's visit have the proper criminal record clearance/exemption on file. At least one person trained in CPR and Pediatric First Aid is present while children are in care. Personnel files contained a health screening. Required personnel have current mandated reporter training and current immunizations on file. The person who signs the child in/out uses their full legal signature and records the time of the day. Children's files contained the required emergency identification information, menus were observed to be posted at least on week in advance in a place visible by the child's authorized representative. See 809-C for second page of report....

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie Otsuji	TELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

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: GAN SAMEACH NURSERY SCHOOL	FACILITY NUMBER: 010213705
	VISIT DATE: 10/22/2021

NARRATIVE

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Facility representative 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.

Director is reminded that unusual Incidents must be reported within 24 hours by phone. Written report is to follow within 7 days utilizing form LIC624. LPA informed the Director that all forms can be downloaded at www.ccld.ca.gov and encouraged the Director to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The Director was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

This facility plans to provide Incidental Medical Services - IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 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

LPA is requesting a current LIC 500 (Personnel Roster) and LIC 9040 (Child Care Facility Roster) to be submitted to LPA no later than 11/22/2021.

An exit interview was conducted with the Director, Annie Jacob. No deficiencies are being cited on today's date. The Director was provided a copy of their appeal rights and the signature on this form acknowledges receipt of these rights. A Notice of Site visit was posted at the time of inspection and must remain posted for 30 days.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie Otsuji	TELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021

LIC809 (FAS) - (06/04)

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