013414320-7-20-2022-52-CC-JSAI-CGHPCT-20220720111228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013414320
Report Date: 07/20/2022
Date Signed: 07/20/2022 11:12:50 AM

Document Has Been Signed on 07/20/2022 11:12 AM - 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:	AGNEW, DOROTHY & STEPHENS, CLEOTHA		FACILITY NUMBER:	013414320
ADMINISTRATOR:	AGNEW, DOROTHY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 614-9156
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	14	CENSUS: 11	DATE:	07/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Assistant teacher Abeer Nasser		TIME COMPLETED:	11:35 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analysts (LPAs) Jyoti Saini and April wright met with Assistant Teacher for an unannounced Annual Random Inspection. LPAs disclosed the purpose of the inspection and was granted entry into the facility by the staff. Licensee Dorothy Agnew, arrived during the inspection. Present during this inspection two helpers supervising 2 infants, 7 preschoolers and 2 school-age. Licensee lives in the house with her husband. All adults requiring background clearance have been cleared and associated to this facility. The hours of operation are 7:00AM- 5:30PM, Monday -Friday.

ON LIMITS: The large play room located near the back of the home, and converted driveway adjacent to the day care area, short hallway through living room and bathroom.

OFF LIMITS: The master bedroom and garage.

LPAs inspected the house for health and safety hazards. Daycare Area is clean, orderly, and equipped with age appropriate toys and equipment for children, indoors and outdoors. Home has a working telephone, a working smoke and carbon monoxide detector, and a fire extinguisher that meets the minimum requirements. There are ample of age appropriate toys that appear to be safe and in good condition. There is a hot tub in in off limit area and made inaccessible to the children. The fully fenced back play area is available for children in care. The Licensee has a trampoline in the backyard. LPAs advised her that she must comply with the manufacturer instructions listed on the trampoline, including supervision requirements, if any of the day care children use the trampoline. LPAs did not observe any hazardous materials or toxins accessible to children during today’s inspection. Licensee provides daily snacks and lunch. Discipline policy is redirection. LPAs reviewed children’s files. All the files are complete and up to date. All required postings are properly posted.

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: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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 2

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: AGNEW, DOROTHY & STEPHENS, CLEOTHA	FACILITY NUMBER: 013414320
	VISIT DATE: 07/20/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPAs discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com

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.

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

Exit interview conducted and report was reviewed with the licensee Dorothy Agnew

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti Saini	TELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2