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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013414625
Report Date: 12/01/2021
Date Signed: 12/01/2021 11:10:28 AM

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 - VALLEJO MILLFACILITY NUMBER:
013414625
ADMINISTRATOR:HADFIELD, ELAINEFACILITY TYPE:
840
ADDRESS:38569 CANYON HEIGHTS DRIVETELEPHONE:
(510) 742-6440
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:75CENSUS: 1DATE:
12/01/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Elaine HadfieldTIME COMPLETED:
11:12 AM
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On December 1, 2021 at approximately 8:30am LPA Haderer made an unannounced visit as a follow up to the annual inspection done on November 10, 2021 and sign the Civil Penalty Assessment form from the November inspection. There were two teachers present and no children. The LPA was told the site director was scheduled to arrive at 10:00am. LPA left the facility at 8:50am.

LPA Haderer returned at approximately 10:30am and met with the site director, Elaine Hadfield. There was one child in care (5 year old female) an no other teachers were present.

LPA and the site director signed the Civil Penalty Assessment form LIC421M from the November 10, 2021 visit. LPA printed the Site Visit form and left the facility.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021
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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