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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010214923
Report Date: 02/14/2023
Date Signed: 02/14/2023 02:23:31 PM


Document Has Been Signed on 02/14/2023 02:23 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 - MISSION SAN JOSEFACILITY NUMBER:
010214923
ADMINISTRATOR:NORRIS, JANETFACILITY TYPE:
840
ADDRESS:43545 BRYANT STREETTELEPHONE:
(510) 490-7874
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:115CENSUS: 9DATE:
02/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Janet NorrisTIME COMPLETED:
02:40 PM
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On 2/14/2023 Licensing Program Analyst (LPA) Melanie Otsuji met with Director Janet Norris for an UNANNOUNCED 1 YEAR-REQUIRED INSPECTION. Present during today's visit was 1 additional staff member and 9 school aged children. This is an after school facility that operates on the Mission San Jose Elementary School campus in one portable and the Auditorium as needed. The facility operates from 7:00am – 6:00pm Monday – Friday. Staff are on break and not on site from 9:30AM - 11:30AM.

The facility has ample age appropriate materials in the classroom that were observed to be clean, in good condition and age appropriate for the children present. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Facility utilizes the Elementary School bathrooms and staff ensure that children do not commingle with the Elementary school children. All children have access to clean drinking water. There is a working carbon monoxide detector and smoke detectors, and a fully charged fire extinguisher. The play yard is shared with the elementary school children. The facility has a play yard schedule to ensure no commingling. LPA did not observe any harmful or unattended bodies of water in or around the facility.

The facility is operating within its licensed capacity and is in ratio. All proper postings are made visible by the entrance. All food is labeled and properly stored. The fire/disaster drill log was complete with the last drill logged 2/1/2023. All medications are properly stored and documented. A physical census of the children and staff were taken and cross referenced with the sign-in and out log. All children were accounted for and properly signed in and all staff have obtained a criminal record clearance. LPA reviewed 2 staff files and 5 children files. All files were observed to be complete.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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 - MISSION SAN JOSE
FACILITY NUMBER: 010214923
VISIT DATE: 02/14/2023
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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.

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.

No citations noted on today's date, 2/14/2023. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director, Janet Norris.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
LIC809 (FAS) - (06/04)
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