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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412462
Report Date: 10/28/2021
Date Signed: 10/28/2021 02:48:16 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 - GLENMOORFACILITY NUMBER:
013412462
ADMINISTRATOR:VINK, KELLYFACILITY TYPE:
840
ADDRESS:4620 MATTOS DRIVETELEPHONE:
(510) 744-0772
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:60CENSUS: 6DATE:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH:Heather PitruzzelloTIME COMPLETED:
02:55 PM
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On October 28, 2021 at approximately 10:07am, 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 Heather Pitruzzello, another teacher and 6 children in care (5 years-old). During the inspection those 5 children left for school and 6 other new children arrived. The center currently operates from 7:00 to 6:00PM.

The child care center operates in a large portable room on the campus of Glenmoor Elementary School. The children use the school yard and playground, all 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. 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 conducts fire inspections, the last one was completed 9/24/2021. The carbon monoxide detector was 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 in the staff kitchen area out of the access of children. There are no bodies of water accessible to children in care. Children bring their own food from home; the center provides snacks. There was a gallon of 2% milk for children’s consumption in the refrigerator. Milk for children should be 1% or non-fat milk unless requested by child’s parent or physician. Please see LIC809D for deficiency.

Children use the school bathrooms on campus, children are escorted in groups when they need to use the facilities. The staff has a separate adult bathroom located on campus.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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 7
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 - GLENMOOR
FACILITY NUMBER: 013412462
VISIT DATE: 10/28/2021
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Disaster drills are conducted at least once each month, the last drill was conducted September 24, 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. There is one child that requires incidental medication (EpiPen’s), medications were not expired, and signed parent authorization form was in the file.

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. One staff (teacher’s aide) file reviewed did not have the Health History report showing TB immunization (staff just had the Covid vaccination and must wait to take the TB test). Staff member schedule for a screening on November 30, 2021.

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.

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

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: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
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 - GLENMOOR
FACILITY NUMBER: 013412462
VISIT DATE: 10/28/2021
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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.

One deficiency was cited today, please see 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 Heather Pitruzzello.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC809 (FAS) - (06/04)
Page: 3 of 7
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 - GLENMOOR
FACILITY NUMBER: 013412462
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021

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 2% milk in the refrigerator for the consumption of children in care (not 1% or non-fat) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2021
Plan of Correction
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Deficiency was cleared this day as the 2% milk was disposed of and 1% will be provided starting tomorrow 10/29/2021.
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: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021
LIC809 (FAS) - (06/04)
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