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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412610
Report Date: 07/09/2024
Date Signed: 07/09/2024 01:33:07 PM


Document Has Been Signed on 07/09/2024 01:33 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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
013412610
ADMINISTRATOR:JAMIE CZELUSNIAKFACILITY TYPE:
830
ADDRESS:4655 LASSEN ROADTELEPHONE:
(925) 455-1560
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:36CENSUS: 24DATE:
07/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:37 AM
MET WITH:Jamie CzelusniakTIME COMPLETED:
01:31 PM
NARRATIVE
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On 7/9/2024 at 8:37am Licensing Program Analyst (LPA) Morgan Pringle met with Director Jamie Czelusniak for an Unannounced Case Management visit. An unusual incident was self-reported by the facility on 6/28/2024 regarding a lack of supervision. Present during the visit were twenty-four (24) infants and seven (7) additional staff members.

On 6/27/2024 at approximately 4:59pm a child was left unattended on the playground after all the other children and two (2) staff members had returned back inside the classroom. One of the teachers was notified by a parent that had just entered the facility that a child was outside on the playground alone. Facility staff stated that they looked around the yard before returning inside, but the child was behind the door next to the water fountain and they had not looked behind the door. Facility staff also stated that they did not complete the face-to-name check list when returning inside. Facility staff stated the child was outside for approximately one (1) minute before the parent informed her.

Due to the lack of supervision, the facility is being issued a Type A Violation today and a $500.00 civil penalty is also being assessed. LPA Pringle informed Director that this report dated 7/9/2024 document(s) 1 Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
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 3


Document Has Been Signed on 07/09/2024 01:33 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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 013412610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/10/2024
Section Cited
CCR
101429(a)(1)

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101429(a) In addition to Section 101229, the following shall apply: (1) Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times.
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Staff will watch the "Supervising Children in Child Care Centers" on the CCLD website. Director will create a written statement stating new protocols put in place to follow in order to prevent a child in care being left without supervision. All staff will sign and date the statements
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This requirement was not met as evidenced by: A child was left outside on the playground without supervision which poses an immediate risk to the health, safety and personal rights of the children in care.
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acknowledging they have watched the video and understand their responsibility to provide supervision to children at all times and will implement the new protocols put in place. Director will email this signed statement to LPA Pringle by POC date.

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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: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 013412610
VISIT DATE: 07/09/2024
NARRATIVE
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Also, LPA Pringle informed the Director to provide a copy of this licensing report dated 7/9/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224), or other written statement, must be placed in the child's file for verification.

Notice of site visit was given and must remain posted for 30 days.



Failure to comply with posting requirements shall result in the immediate civil penalty of $100.

Exit interview and report was reviewed with Director Jamie Czelusniak.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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