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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417033
Report Date: 10/24/2022
Date Signed: 10/24/2022 11:07:07 AM


Document Has Been Signed on 10/24/2022 11:07 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:FREMONT PARENTS NURSERY SCHOOLFACILITY NUMBER:
013417033
ADMINISTRATOR:MILLER, JESSICAFACILITY TYPE:
850
ADDRESS:4200 ALDER AVENUETELEPHONE:
(510) 793-8531
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:24CENSUS: 11DATE:
10/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica MillerTIME COMPLETED:
11:00 AM
NARRATIVE
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On October 24, 2022 at approximately 8:30am, Licensing Program Analyst (LPA) Haderer arrived unannounced to open and investigate the complaint. There was 1 teacher present, the director arrived by 8:50am. During the visit, 11 children and 7 parents and a 1 child therapist arrived to the facility.

It was found that procedure for reporting an Unusual Incidents were not followed,

Title 22 regulation 101212(d)(1)(B) Reporting Requirements states:

d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
(1) Events reported shall include the following:

(B) Any injury to any child that requires medical treatment.


A deficiency was issued for this, see LIC809D.

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

Exit interview conducted and report was reviewed with the center director, Jessica Miller.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
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 10/24/2022 11:07 AM - 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 STE 1102
OAKLAND, CA 94612


FACILITY NAME: FREMONT PARENTS NURSERY SCHOOL
FACILITY NUMBER: 013417033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2022
Section Cited

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101212 d) Upon the occurrence, during the operation of the child care center of any of the events.....a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information... shall be submitted to the Department within seven days
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(1) Events reported shall include the following:
(B) Any injury to any child that requires medical treatment.
This requirement was not met since no incident reports were called in or filed which poses a potential Health and Safety risk to children in care.
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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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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