010214925-11-15-2022-52-CC-KPHN-CL7SMN-20221115130013

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 010214925
Report Date: 11/15/2022
Date Signed: 11/15/2022 01:00:30 PM

Document Has Been Signed on 11/15/2022 01:00 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 - ARDENWOOD		FACILITY NUMBER:	010214925
ADMINISTRATOR:	GONZALEZ, YESSICA		FACILITY TYPE:	840
ADDRESS:	33955 EMILIA LANE		TELEPHONE:	(510) 797-6280
CITY:	FREMONT	STATE: CA	ZIP CODE:	94555
CAPACITY:	90	CENSUS: 12	DATE:	11/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Luigi Bozzo		TIME COMPLETED:	01:20 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	On 11/15/2022 approximately at 8:45AM, Licensing Program Analyst (LPA) Kelly Phan met with Luigi Bozzo (Center Director) for an unannounced required 1 year inspection. Present for this inspection are 12 school aged children and three fingerprinted and associated staff members. The facility is in ratio today. Facility operating hours are 7AM to 6PM Monday, Tuesday, Thursday, and Friday; Wednesday 8:30AM to 11:15AM. The facility was toured to conduct a health and safety inspection. At 9:00AM, LPA toured the facility classroom. The facility is utilizing a portable on the site of Ardenwood Elementary school. The classroom is tidy and clean with heating and ventilation for safety and comfort. There are safe age-appropriate toys and learning materials available to children throughout the classroom. Each child has individualized space for their personal belongings. All hazardous materials and toxins including disinfectants and cleaning solutions were observed to be made inaccessible to children during today's inspection. Food, beverages, and medications are kept in refrigerator; all food and drinks are in original containers and are not expired. The facility is providing filtered drinking water with disposable cups or ask children to bring their own water bottles to be used inside and outside the facility. LPA reviewed storage and documentation of children's medications; all medications are made inaccessible to children as it is kept in a locked cabinet and medications are in original containers with unaltered instructions and are not expired. LPA recommends the director to use LIC 9221 (Parent Consent form for Administrating Medications) to maintain both prescription and non-prescription medications; there is also a first aid kit stored in the class. There are two fully charged 3A40BC fire extinguishers and smoke detector are inspected once a year per center director. There is also a working carbon monoxide detector and working telephones in the class. Both fire and earthquake drills were last conducted on October 20, 2022. All required forms are posted in public view. Children are able to bring their own food or will have provided meals from the elementary school. SEE LIC 809 C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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 - ARDENWOOD	FACILITY NUMBER: 010214925
	VISIT DATE: 11/15/2022

NARRATIVE

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At 9:30AM, The play structures was observed to be operable and age-appropriate during this inspection. The playground is shared with other children of Ardenwood Elementary School. Areas around slides and high climbing equipment have wood chips to absorb any falls. There are also plenty of trees to provide shade. There are no pools, hot tubs, ponds, or any other bodies of water accessible to children. The facility also shares two distinguished bathroom areas with Ardenwood Elementary school children; The first bathrooms shared are the ones closest to the play structures and other bathroom location is the bathrooms closest by the classroom portable. Both bathroom are separated and have plenty of paper and soap supplies.

At 10:00AM, LPA reviewed 5 staff files and found that there Staff#2 was missing LIC 501 (Personnel Report), Staff#4 had expired mandated reporter training and expired CPR and first aid card, however the individual is no longer working at the facility; Staff#1 did not have any admin units present. Six children files were also reviewed and found that the facility is utilizing their own forms, which contains similar information for required licensing forms. LPA also reviewed the sign in/out sheet and found that there are 11 signatures out of 12 children present today. LPA advised the director to remind children parents to sign in/out daily to maintain proper ratio of children and assuming responsibility for each child present. Facility roster was reviewed and a copy was obtained along with LIC 610A (Emergency disaster plan) and LIC 500 (Personnel Report).

There was 1 deficiency cited today
Type B: LPA observed and reviewed that 11 signatures out of 12 children present today. 1 signature was not recorded for 1 school aged child present during today's inspection.

Appeal rights and a notice of site visit notice was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the center director, Luigi Bozzo.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

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 - ARDENWOOD	FACILITY NUMBER: 010214925
	VISIT DATE: 11/15/2022

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Incidental Medical Services (IMS) policy was discussed. This facility provides IMS to children in care. The facility is following and have developed IMS plan on file. When any changes to the IMS plan is made, an updated Plan for Providing IMS must be submitted to the Department. 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.”

Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

Licensee was reminded that California Law requires licensed Child Care Centers to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the Facility Representative that all forms can be downloaded at www.ccld.ca.gov and encouraged the Facility Representative to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Licensee 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.

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/process.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 11/15/2022 01:00 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 - ARDENWOOD	FACILITY NUMBER: 010214925
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101529.1(b)

Sign In and Sign Out

(b) Center staff shall sign in a school-age child who arrives at the center on his/her own. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the facility representative did not comply with the section cited above as there were only 11 signatures out of 12 children present day, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2022
	Plan of Correction
1 2 3 4	Director will create an immediate plan to enforce every child is sign in/out everyday and communicate verbally with staff members to ensure it is followed by children's parent Director will send action plan to LPA by 11/15/2022 via email

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022

LIC809 (FAS) - (06/04)

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