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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416337
Report Date: 06/25/2021
Date Signed: 06/25/2021 10:18:08 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:PIERCE, FORRESTINEFACILITY NUMBER:
013416337
ADMINISTRATOR:PIERCE, FORRESTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 581-1109
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:14CENSUS: 7DATE:
06/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Forrestine Pierce- LicenseeTIME COMPLETED:
10:30 AM
NARRATIVE
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On 6/25/21 at 9:44am, LPA Plumboy conducted an unannounced Case Management Inspection with Licensee Forrestine Pierce. Present for the inspection was licensee's fingerprint clear and associated daughter Myah Underwood, licensee's fingerprint clear and associated husband Paul Pierce Jr., 4 infants, 2 preschool age children, and 1 school age child. On 6/18/21, licensee self reported C1 left the facility unobserved by staff due to a gate being left open by a parent. The child was observed by neighbors who contacted licensee. Licensee then found the child unharmed with her neighbor on the neighbor's porch. Licensee stated child was gone for a total of approximately 5 to 10 minutes. Licensee stated and it was observed by LPA Plumboy that a double child safety gate has been added to the childcare gate in which the child walked out from.

See 809D for deficiency. The attached Type A deficiency is cited today. Upon receipt, licensee shall post for 30 days and provide copies of this licensing report to parent/guardians of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 Acknowledgement of Receipt of Licensing Reports should be signed by guardians and placed in each child’s file.
Appeal rights were given & discussed. This report must be available for 3 years. An exit interview was conducted & a site visit notice posted adjacent to the main entry doorway for 30 days. Failure to do so will result in a $100 civil penalty fine.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
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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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: PIERCE, FORRESTINE
FACILITY NUMBER: 013416337
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/28/2021
Section Cited

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The licensee shall be present in the home and shall ensure that children in care are supervised at all times.
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This requirement was not met as evidenced by the licensee self reporting to CCLD. This poses an immediate risk to the health and safety of children in care.
A CHILD WAS GONE FROM THE FACILITY FOR APPROXIMATLY 5 TO 10 MINUTES. AN LIC 421IM FORM WAS GIVEN.
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ANY SUBSEQUENT VIOLATIONS OF LACK OF SUPERVISION WITHIN A 12 MONTH PERIOD MAY RESULT IN A $1000 CIVIL PENALTY.

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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: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:
DATE: 06/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2021
LIC809 (FAS) - (06/04)
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