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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010216259
Report Date: 04/07/2022
Date Signed: 04/07/2022 04:30:14 PM


Document Has Been Signed on 04/07/2022 04:30 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 - MALONEYFACILITY NUMBER:
010216259
ADMINISTRATOR:SHAH, SANGITAFACILITY TYPE:
840
ADDRESS:38700 LOGAN DRIVETELEPHONE:
(510) 797-5373
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:60CENSUS: 1DATE:
04/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Sangita ShahTIME COMPLETED:
04:45 PM
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On April 7, 2022 at approximately 12:50pm Licensing Program Analyst (LPA) Russ Haderer arrived to conduct an unannounced random annual site inspection for this school age facility. LPA met with facility director, Sangita Shah and toured the facility for a health and safety inspection. Present at the time of this inspection was one the director, one school age child in care and the child’s therapist. During the inspection, 3 additional staff and 20 additional school age children arrived. Adults present are background cleared and associated to this facility.

The facility is a single-story portable classroom on the campus of the Maloney Elementary school. There is an outdoor playground and large blacktop area. There are separate boys and girls bathrooms available in the building next door adjacent to the playground area. Heating and ventilation is acceptable. All required posted documents were found to be in compliance and prominently posted in public places.

There are 2 fully charged 3A40BC fire extinguishers last serviced on 7/15/2021. The room has a working carbon monoxide detector (tested and working), smoke detectors are monitors by the school fire alarm system, the last check made by 8/11/2021 showed all detectors were tested and functioning. The facility has monthly fire and/or earthquake drills, the last one completed was on 3/10/2022.

The school does not currently provide lunch, snacks are available. During the inspection, some expired snacks were found in the supplies cupboard and refrigerator. See LIC809D.

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. All hazardous materials and toxins are kept out of the reach of children.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
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 5


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 - MALONEY
FACILITY NUMBER: 010216259
VISIT DATE: 04/07/2022
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The facility uses a traditional sign-in/sign-out log. All children present were properly signed in. The classrooms has trash bins with tight fitting covers to dispose of solid waste. The facility has one child that require incidental medication in case of expose to a peanut allergy (EpiPen’s, and anti-histamine) Medications were checked and unexpired medication was available, however, there was also some older expired medication that had not been returned to the parents for disposal. A Technical Violation was issued.

The school is secured by a 6-foot fence and secured with gates. All play equipment 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 in the play areas and teachers are always present.

At 2:55pm staff records were reviewed. All records were in good order. At 3:25pm, children’s files were reviewed. All files found to be complete and in good order.

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

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 - MALONEY
FACILITY NUMBER: 010216259
VISIT DATE: 04/07/2022
NARRATIVE
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There was 1 deficiency issued today, see LIC809D. 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 Sangita Shah.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/07/2022 04:30 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 - MALONEY
FACILITY NUMBER: 010216259

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101227(a)(1)
Food Service
(a) In child care centers providing meals to children, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the children. Each meal shall include, at a minimum, the amount of food components as specified by Title 7, Code of Federal Regulations, Part 226.20, (Revised January 1, 1990) Requirements for Meals, for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that expired snack foods were found in the supply cabinet and refrigerator which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/07/2022
Plan of Correction
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Site Director immediately cleared the expired foods and placed them in the trash bins.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5