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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013414235
Report Date: 02/05/2024
Date Signed: 02/05/2024 04:21:13 PM


Document Has Been Signed on 02/05/2024 04:21 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:MY SPACE TO GROWFACILITY NUMBER:
013414235
ADMINISTRATOR:CASTAIN, CYNTHIAFACILITY TYPE:
830
ADDRESS:7197 AMADOR VALLEY BOULEVARDTELEPHONE:
(925) 829-4063
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:8CENSUS: 1DATE:
02/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Acting director, Selina HernandezTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Jyoti Saini arrived at the Facility unannounced for a 10-day complaint visit. Upon arrival at 8:52 am, LPA observed the volunteer (unassociated) supervising one (1) infant in the infant classroom. Potential licensee Priyanka Boga (unassociated) (pending change of ownership) and acting director Selina Hernandez arrived during the inspection. The potential licensee, Priyanka Boga, mentioned that the Facility had submitted the request to the community care licensing division (CCLD)to associate S1 with the Facility. The record review shows that the Facility submitted the request to the Regional Office on Sunday, February 4, 2024, at 8:44 pm; however, the volunteer (S1)has been on the board since 01/02/2024. LPA notified the Facility that All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall, prior to working, residing, or volunteering in a licensed facility.

During the inspection, LPA also observed that the volunteer did not have the required immunization against influenza, pertussis, and measles, and the results of tuberculosis tests were also missing.

See 809-D for the TYPE A and TYPE B deficiencies cited on today's visit.

California Code of Regulations, {Title 22, Division 12, Chapter 1, Section 102370(d) is being cited on the attached LIC809-D. THE LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAY'S VISIT WITH THE NOTICE, AND THE LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR THE AB 633 FACT SHEET AND A COPY OF THE ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH THE PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.

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

Appeals rights were given and reviewed.

An exit interview was conducted, and the report was reviewed with acting director, Selina Hernandez.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2024
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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Document Has Been Signed on 02/05/2024 04:21 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: MY SPACE TO GROW
FACILITY NUMBER: 013414235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/06/2024
Section Cited
CCR
101170(e)(1)

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101170 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 101170(f) or
This requirement was not met as evidenced by:
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The Facility shall ensure that each staff's fingerprint clearance is associated with the Facility prior to working.
600$ Civil Penalty assessed today.
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Based on observation, interview, and record review, the Licensee did not comply with the section cited above.S1 (volunteer) and S2 (potential Licensee) supervising the infant are not associated with the Facility which poses an immediate risk to the health and safety of children in care.
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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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/05/2024 04:21 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: MY SPACE TO GROW
FACILITY NUMBER: 013414235

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/12/2024
Section Cited
HSC
1596.7995(a)(1)

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(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:
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 The director shall ensure that staff/volunteer has proof of immunization prior to work.
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Based on record review, the licensee did not comply with the section cited above, The volunteer (S1) personnel file did not contain proof of measles (MMR) nor Pertussis (Tdap) vaccinations which poses a potential health, safety or personal rights risk to persons in care.
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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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2024
LIC809 (FAS) - (06/04)
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