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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010214922
Report Date: 09/23/2021
Date Signed: 09/23/2021 12:18:55 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 - BROOKVALEFACILITY NUMBER:
010214922
ADMINISTRATOR:NAGAYO, JESSICAFACILITY TYPE:
840
ADDRESS:3400 NICOLET AVENUETELEPHONE:
(510) 797-5180
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:75CENSUS: 5DATE:
09/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Jessica NagayoTIME COMPLETED:
12:25 PM
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On September 23, 2021 at approximately 8:01am, LPA Haderer arrived unannounced for an annual inspection for compliance to Health and Safety. The new CARE tool was used for the inspection. Present for the inspection was the site director Jessica Nagayo, two teachers Marzia Salem and Mikaela Tocus and 5 children in care (TK to 6th grade). During the inspection the first group of children left and a 6 other children arrived (TK to K),

The facility is operated on the campus of Brookvale elementary school. The facility is a single portable room. The children use the school yard and playground, all is in safe condition and free from sharp, loose or pointed parts and the areas around or under high climbing equipment has appropriate cushioned material that absorbs a fall. Shade was available under building eaves and trees in the play areas and teachers are always present.



The facility has a fully charged 3A40BC fire extinguisher by the exit door on the southern side of the room. The last annual inspection was done 8-15-2021. There is a working carbon monoxide detector (tested and working). Fremont Fire Dept. completed and passed recent fire inspection on 7/29/2021 (document in file).

Heating and ventilation was acceptable. There is a menu showing snack times. The facility is clean and well organized with ample age appropriate furnishings and equipment. Surfaces including floors and counter tops are clean and toxic free. There were no hazardous items/toxins observed to be accessible to children in care today. There are no bodies of water accessible to children in care.

There are children’s bathrooms on campus, the boys bathroom has 2 urinals and one sink, the girls bathroom had 3 toilets and one sink. The sinks have functioning water taps with appropriate hand washing signs. There are enough towels and soap supplies. All toilets, handwashing and cleaning areas are in safe and sanitary operating condition.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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: ADVENTURE TIME - BROOKVALE
FACILITY NUMBER: 010214922
VISIT DATE: 09/23/2021
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Disaster drills are conducted every month, the last drill was conducted August 31, 2021

The sign in/out sheets were reviewed. Classrooms have trash cans with tight fitting cover for the disposal of solid waste. The facility has two children that require incidental medication (EpiPen’s, inhalers and anti-histamines for allergies). Medications are stored in a locked cabinet near the teacher’s desk. Medications were checked and all are current, nothing expired.

Children's records were reviewed: LPA requested and reviewed facility roster. All files selected were complete and up to date. The parent consent form for medical treatment is is built into the Parent Agreement form and signed by the parent.

Staff files were reviewed. All staff subjected to criminal review have been cleared and associated to the facility. All files were complete, up to date and found to be in compliance with Title 22 regulations. Immunization records for Tdap, MMR and flu shot were available.

All documents required to be posted were appropriately posted on the walls: License; Emergency Disaster Plan; Earthquake Preparedness checklist; Notification of Parents Rights; Personal rights; Child seatbelt laws; menus; daily activity schedules. There are no waivers for this facility.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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

Site 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.

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

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
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 - BROOKVALE
FACILITY NUMBER: 010214922
VISIT DATE: 09/23/2021
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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/inspection-process.

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



Exit interview conducted and report was reviewed with the Site Director Jessica Nagayo.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2021
LIC809 (FAS) - (06/04)
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