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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013414632
Report Date: 09/22/2021
Date Signed: 09/22/2021 03:43:31 PM

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:PRINCIPLED ACADEMY, THEFACILITY NUMBER:
013414632
ADMINISTRATOR:FLORENDO, AURELIAFACILITY TYPE:
850
ADDRESS:2305 WASHINGTON AVENUETELEPHONE:
(510) 351-6400
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:34CENSUS: 27DATE:
09/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Aurelia FlorendoTIME COMPLETED:
03:30 PM
NARRATIVE
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On 9/22/2021 at 11:20am Licensing Program Analyst (LPA) Morgan Pringle met with Director Aurelia Florendo for an Unannounced Annual Inspection. Two (2) classrooms, The Green Room and The Blue Room, were toured for a health and safety inspection. Twenty-seven (27) preschool children and four (4) staff members were present during the inspection. The facility operates from 7:00am – 6:15pm.

The facility has age appropriate materials in all classrooms that are observed to be clean and in good condition. The outdoor space has ample shade for the children and has proper materials. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. All sinks and toilets were observed to be clean and in proper working order. The food preparation areas were observed to be clean and free from hazards. All knives and cleaning products in the food prep areas were made inaccessible to children in care. LPA did not observe any harmful or unattended bodies of water in or around the facility.

The facility is operating within its licensed capacity and is in ratio. All proper postings including the menu were made visible to parents and visitors on the front door of each classroom. The fire and disaster drill log is complete with the last drill logged 8/9/2021. A physical census of the children and staff was taken and cross referenced with the sign-in and out log. One (1) child is missing a parent/guardian signature for today’s date (see LIC809-D).

LPA obtained all the children’s files and the staff files. All children’s files were complete. Two (2) teachers were missing a Mandated Reporter certificate of completion. One (1) teacher was missing a full fingerprint clearance (see LIC809-D)

Continued on LIC809-C

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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 4
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: PRINCIPLED ACADEMY, THE
FACILITY NUMBER: 013414632
VISIT DATE: 09/22/2021
NARRATIVE
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Director was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Personnel Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. Director was reminded that California Law requires all facilities to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Director that all forms can be downloaded at www.ccld.ca.gov. Director was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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.

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.

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.

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

Exit interview conducted and report was reviewed with Director Aurelia Florendo.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: PRINCIPLED ACADEMY, THE
FACILITY NUMBER: 013414632
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/06/2021
Plan of Correction
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Tecahers will complete Mandated Reporter training and Director will submit proof by 10/6/2021
Type B
Section Cited
CCR
101170(e)(1)
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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2021
Plan of Correction
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Teacher will not continue work at the facility until full clearance is received. Upon clearance, teacher may resume work.
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: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2021
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: PRINCIPLED ACADEMY, THE
FACILITY NUMBER: 013414632
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229.1(b)
Sign In and Sign Out
(b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2021
Plan of Correction
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Director will obtain signature from child's authorized representative and submit proof to LPA by 9/24/2021
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 09/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2021
LIC809 (FAS) - (06/04)
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