013414235-2-15-2023-52-CC-JSAI-CP3T7X-20230215132929

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013414235
Report Date: 02/15/2023
Date Signed: 02/15/2023 01:30:01 PM

Document Has Been Signed on 02/15/2023 01:30 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:	MY SPACE TO GROW		FACILITY NUMBER:	013414235
ADMINISTRATOR:	CASTAIN, CYNTHIA		FACILITY TYPE:	830
ADDRESS:	7197 AMADOR VALLEY BOULEVARD		TELEPHONE:	(925) 829-4063
CITY:	DUBLIN	STATE: CA	ZIP CODE:	94568
CAPACITY:	8	CENSUS: 6	DATE:	02/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Director, Cynthia Castain		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Jyoti Saini met with director Cynthia Castin for an unannounced Annual Random Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the director. In addition to the director, there are 6 children and 3 staff present today. The facility operates Monday - Friday from 7:30am to 5:30 PM. The facility was inspected indoor and outdoor today for health and safety hazards and the following was observed; There are no bodies of water, firearms, or weapons on the premises. The center is in good condition with proper temperature and ventilation and is free of any hazards. All furniture is in good repair. The Center has age-appropriate toys and equipment. A first aid kit and a first aid backpack are available. The outdoor play area is fenced for supervision. The play structure is age-appropriate and in good condition with sufficient cushioning underneath. The staff has separate bathroom. The bathrooms appear to be safe, sanitary, and free of any hazardous items. There is drinking water readily available for children. The facility provides lunch and snacks and menu is posted. The classroom has appropriate postings. The last Emergency Drill was conducted on 12/15/2022 and is properly logged.

LPA reviewed sign-in and out sheet. The center has a complete record of sign-in/out sheets by an authorized pick up person. There is a working fire alarm system in the facility. The Facility has a working smoke and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone available.

All the Children records reviewed were complete. All children have a record of emergency identification information on file. LPA observed Individual Infant Sleep Plan (LIC9227) for all infants under the age of 12 months. LPA reviewed sleep record log for 15-minute checks. The classroom has a diaper changing table, sleeping mats, and cubbies with children’s names on them. All staff has a criminal record clearance on file. The site Director has a current Pediatric First Aid/CPR certificate on file. Director understands that there shall be at least one person, with valid CPR and First Aid certifications, on site always or present during off-site activities (field trips). Facility roster was reviewed, and a copy was obtained.

See next page...

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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: MY SPACE TO GROW	FACILITY NUMBER: 013414235
	VISIT DATE: 02/15/2023

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During inspection,

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. This facility does not provide IMS (Incidental Medical Services) to children currently. If any IMS is provided, a Plan for Providing 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/process.

There are no deficiencies cited today.

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

Exit interview conducted and report was reviewed with the facility representative, Cynthia Castain.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC809 (FAS) - (06/04)

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