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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013411129
Report Date: 10/20/2021
Date Signed: 10/20/2021 12:30:25 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 - NILESFACILITY NUMBER:
013411129
ADMINISTRATOR:JAYJAY NAGAYOFACILITY TYPE:
840
ADDRESS:37141 2ND STREETTELEPHONE:
(510) 797-4806
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:110CENSUS: 16DATE:
10/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:59 AM
MET WITH:Kristie ArrendondoTIME COMPLETED:
12:40 PM
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On October 20 2021 at approximately 7:59am, 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 Kristie Arrendondo, one staff member and 16 children in care (Kindergarten to 6th grade). The center currently operates from 7:00AM to 6:00PM.

The child care center operates in a large portable room on the campus of Niles Elementary School. 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. Some of the material is getting thin on the landing area of the slides (through use). This material needs to be replenished or raked back into place. Shade was available under building eaves and large trees on the property line and near the main school buildings. Access to drinking water is available and teachers are always present.



The facility has 2 fully charged 3A40BC fire extinguishers, one mounted next to each door in the classroom. The last annual inspection was done 7/15/2021. Fremont Fire Department conducted fire inspection on 8/12/2021 and no violations were observed at time of inspection. The smoke alarm and carbon monoxide detectors were tested and functioning. Heating and ventilation in the classroom is acceptable.

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. Hazardous items/toxins are kept in a locked cabinet, one of the doors of the cabinet was not locked (handle with lock was broken and turning freely). There are no bodies of water accessible to children in care. Children bring their own food from home, the center provides snacks. LPA noted that with the exception of one can of chocolate pudding, food was within expire date. LPA also observed 2% milk in the refrigerator. See LIC809D for deficiencies cited today.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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 - NILES
FACILITY NUMBER: 013411129
VISIT DATE: 10/20/2021
NARRATIVE
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Children use the school bathrooms, which are many and ample in size. There are enough towels and soap supplies. The staff have separate adult bathrooms located in the school.

Disaster drills are conducted at least once every six months, the last drill was conducted September 9, 2021



The sign in/out sheets were reviewed and are accurate. Classrooms have trash cans with tight fitting cover for the disposal of solid waste. At this time, the facility does not have any children that require any incidental medication (EpiPen’s, inhalers and anti-histamines for allergies).

Children's records were reviewed: LPA requested and reviewed facility roster. All files selected were complete and up to date.

Staff files were reviewed. Opening and closing staff have current CPR and first aid training. All staff subjected to criminal review have been cleared and associated to the facility. Mandated Reporter training was current for all reviewed files. Some staff files were missing proof of MMR, and TB vaccinations. Flu shots are being scheduled. See LIC809D for deficiency report.

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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

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: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
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 - NILES
FACILITY NUMBER: 013411129
VISIT DATE: 10/20/2021
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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.

There were deficiencies cited today, please refer to LIC809D for details.



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

DATE: 10/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 3 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 - NILES
FACILITY NUMBER: 013411129
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

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 as the lock was broken on the cabinet that holds cleaning chemicals rendering it unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
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Licensee will get lock repaired so that it maintains the security of all cleaning chemicals to prevent any accidental access by children in care.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 staff files did not have proof of MMR or TB tests which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/27/2021
Plan of Correction
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Site director will collect proof of immunization records and place them in the personnel file. Site director will conduct a full inventory of all staff files to ensure they all have proof of immunization for all staff present in the facility.
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: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 4 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 - NILES
FACILITY NUMBER: 013411129
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2021

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 as there was a can of expired chocolate pudding and expired box of twinkies in the dry good storage, and 2% milk in the refrigerator (instead of 1% or non-fat milk) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2021
Plan of Correction
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Deficiency was cleared this day, the expired food was removed and the 2% milk was replaced with 1% milk.
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: 10/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5