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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415659
Report Date: 04/15/2022
Date Signed: 04/15/2022 02:41:38 PM


Document Has Been Signed on 04/15/2022 02:41 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, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:NIKASIA CHILD CARE CENTERFACILITY NUMBER:
013415659
ADMINISTRATOR:LEWIS, GWENDOLYNFACILITY TYPE:
830
ADDRESS:4143 MAC ARTHUR BOULEVARDTELEPHONE:
(510) 531-9130
CITY:OAKLANDSTATE: CAZIP CODE:
94619
CAPACITY:8CENSUS: 2DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Gwendolyn LewisTIME COMPLETED:
02:45 PM
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On 4/15/22, at 10:15AM, Licensing Program Analysts (LPAs) Catherine Fernandes and Indira Loza met with Director/Owner Gwendolyn Lewis for an unannounced annual inspection. The infant center was inspected to conduct a health and safety check. Present during the inspection were two infants and two additional finger print cleared staff members. The teacher/child ratio was being met today. There is a preschool component on the property with facility number 013417824 located in the same building. This center operates Monday through Friday 9:00AM to 6:00PM.
The day care operates out of three rooms in the back side of the building. As of today no infants require cribs however two cribs are available. The furniture, equipment and activities appear to be age appropriate for the children in care. The heating and lighting is adequate. LPA Fernandes and Loza observed bottled waters available for the infants. The changing table is within arms reach of the sink. LPAs did not observe cleaning supplies or toxic items accessible to children during todays inspection. Lunches and snacks are brought from home. The center does have snacks and food if needed. There are menus posted in the kitchen. The outside play area is a shared space with the preschool which is fenced in. LPAs observed an outdoor wavier for the shared space, center is to make sure the children in the center are outside at the different times. LPAs observed a shaded area and age appropriate toys, that appear to be in good repair. All required documents are posted for public review. Disaster drills are being conducted at least once every 6 months, the last drill was recorded on March 2022. The center is equipped with a fully stocked first aid kit, working cell phone, carbon monoxide detector located in the main area of the day care, fire system is hardwired and there are three 3A40BC fire extinguisher throughout the center. A review of two infant's records and three staff files were reviewed. No IMS is being provided as of right now. There is a staff member with currect CPR during all hours of the day care.

The following items have been cited during the inspection:
- One staff member was missing a physician report
- No staff had proof of a current Mandated Reporter training
Report continued on 809C
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine FernandesTELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
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 04/15/2022 02:41 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: NIKASIA CHILD CARE CENTER
FACILITY NUMBER: 013415659

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

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 in three out of three staff members, which poses a potential safety risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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All staff members will complete Mandated Reporter training and submit a statement when complete by proof of correction date.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

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 in one out of three staff members, which poses a potential health risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Staff member needs a current physician reports then send a statement once complete by proof of correction date.

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: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine FernandesTELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6


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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: NIKASIA CHILD CARE CENTER
FACILITY NUMBER: 013415659
VISIT DATE: 04/15/2022
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LPA Fernandes provided the center with the updated car seat laws, infant sleeping plan and pamphlet for safe sleep.

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.

Director Lewis 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.


LPA discussed the safe sleep regulations with Director 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 Director 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.

See 809D for deficiencies cited during todays inspection.

The following forms need to be submitted by 5/18/22.


Updated floor plan explaining each classroom
LIC 500 Personnel Report
Children's Roster


A notice of site visit was given and must remain posted for 30 days
Exit interview conducted and report was reviewed with the Director Lewis
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR NAME: Catherine FernandesTELEPHONE: (510) 725-7002
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
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