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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013411129
Report Date: 08/26/2022
Date Signed: 08/26/2022 04:14:06 PM


Document Has Been Signed on 08/26/2022 04:14 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 - NILESFACILITY NUMBER:
013411129
ADMINISTRATOR:KRISTIE ARRENDONDOFACILITY TYPE:
840
ADDRESS:37141 2ND STREETTELEPHONE:
(510) 797-4806
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:110CENSUS: 14DATE:
08/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Kristie ArrendondoTIME COMPLETED:
04:25 PM
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On August 26, 2022 at approximately 12:40pm, LPA Haderer arrived unannounced for an annual inspection for compliance to Health and Safety. Present for the inspection was the site director Kristie Arrendondo, three staff members and 14 children in care (Kindergarten to 6th grade). The center currently operates from 7:00AM to 6:00PM.

Adventure Time Niles operates in a portable classroom on the campus of Niles Elementary School. Children have use of the school yard and playground. The playground is free of sharp, loose or pointed parts, areas around or under high climbing equipment has appropriate cushioned material that absorbs a fall. New bark mulch material has been applied under the playground structures. Shade is available under building eaves and large trees on the property line and near the main school buildings. Fresh drinking water is available to children, teachers are always present.

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. There are no bodies of water accessible to children in care. The center provides snacks, children bring their own lunch from home. Dry goods food was checked, everything was within expire date, there was 1% milk in the refrigerator.



The facility has 2 fully charged 3A40BC fire extinguishers, one mounted next to each classroom door. The last annual inspection was done 7-26-2022. Adatto Security & Communications – dba. Fremont Alarm conducted a fire system inspection on 11/30/2021; there were no violations, systems passed. The smoke alarm and carbon monoxide detectors were tested and functioning. Disaster drills are conducted at least once every six months, the last drill was conducted August 19, 2022. Heating and ventilation in the classroom is acceptable. Children use Nile School bathrooms. The staff have separate adult bathrooms located in the school.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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 - NILES
FACILITY NUMBER: 013411129
VISIT DATE: 08/26/2022
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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: All files selected were complete and up to date.

Staff files were reviewed. All staff subjected to criminal review have been cleared and associated to the facility. All staff have current certificates for CPR and first aid training. Two staff files were missing proof of measles vaccination and one individual was missing proof of pertussis vaccinations, see LIC809D for deficiency. One staff has not renewed the Mandated Reporter certificate, see LIC809D for deficiency.

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.

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

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: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
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 - NILES
FACILITY NUMBER: 013411129
VISIT DATE: 08/26/2022
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There were two deficiencies issued today, see LIC809D for deficiencies. 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 site director Kristie Arrendando.

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

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/26/2022 04:14 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 - NILES
FACILITY NUMBER: 013411129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above that proof of measles vaccinations was missing in 2 of 4 staff files reviewed; proof of tdap vaccination missing for 1 of 4 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2022
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 full inventory of all staff files to ensure they all have proof of immunization for all staff present in the facility.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that Mandated Reporter for Child Care Providers (AB1207) was expired for 1 of 4 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/02/2022
Plan of Correction
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Staff will complete the Mandated Reporter AB1207 and place the current certificate in the personnel file.

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: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
LIC809 (FAS) - (06/04)
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