010214922-9-21-2022-52-CC-RHAR-CJGUV4-20220921155431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 010214922
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:54:40 PM

Document Has Been Signed on 09/21/2022 03:54 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 - BROOKVALE		FACILITY NUMBER:	010214922
ADMINISTRATOR:	NAGAYO, JESSICA		FACILITY TYPE:	840
ADDRESS:	3400 NICOLET AVENUE		TELEPHONE:	(510) 797-5180
CITY:	FREMONT	STATE: CA	ZIP CODE:	94536
CAPACITY:	75	CENSUS: 54	DATE:	09/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Grace Sy		TIME COMPLETED:	04:00 PM

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On September 21, 2021 at approximately 1:00pm, Licensing Program Analyst (LPA) Haderer arrived unannounced for an annual inspection for compliance to Health and Safety. Present for the inspection was the site director Grace Sy and 4 fingerprint and associated teachers and 10 children in care (Tk – K). During the inspection, and additional 2 teachers and 44 children (TK to 6^th grade) arrived, for a grand total of 54 children. The facility is in ratio today.

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

There are children’s bathrooms on campus, the boy’s bathroom has 2 urinals and one sink, the girl’s 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.

Heating and ventilation is acceptable. The facility does not provide lunch but does provide snacks. Snack menu is available and posted. Children bring their own bottled water from home and the facility has filtered water available inside and outside the classroom. 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.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell Haderer	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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 - BROOKVALE	FACILITY NUMBER: 010214922
	VISIT DATE: 09/21/2022

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The facility has a fully charged 3A40BC fire extinguisher by the exit door on the south side of the room, tested and serviced 7-26-2022. The last fire inspection and testing was completed by Adatto Security & Communications – dba Fremont Alarm on 11-30-2021. There is a working carbon monoxide detector (tested and working). Disaster drills are conducted monthly, the last drill was conducted August 31, 2022.

Children's records were reviewed: LPA requested and reviewed facility roster, retained a copy. All files selected were complete and in good order. Staff files were reviewed. All staff subjected to criminal review have been cleared and associated to the facility. All files were complete and in good order.

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.

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.

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

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.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell Haderer	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

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 - BROOKVALE	FACILITY NUMBER: 010214922
	VISIT DATE: 09/21/2022

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There were no deficiencies issued today. A copy of this report will remain on file for three years.

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 Grace Sy.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell Haderer	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022

LIC809 (FAS) - (06/04)

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