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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417856
Report Date: 10/17/2022
Date Signed: 11/10/2022 01:37:56 PM


Document Has Been Signed on 11/10/2022 01:37 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 STE 1102
OAKLAND, CA 94612



FACILITY NAME:PEACE TERRACE ACADEMYFACILITY NUMBER:
013417856
ADMINISTRATOR:ROOHI QADIRFACILITY TYPE:
850
ADDRESS:33330 PEACE TERRACETELEPHONE:
(510) 477-9946
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY:29CENSUS: 22DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Roohi Qadir TIME COMPLETED:
01:30 PM
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On October 17, 2022 approximately at 9:05AM Licensing Program Analyst (LPA) Kelly Phan arrived for an unannounced Required-1 Year inspection, and met with director Roohi Qadir. There were 22 children and 5 fingerprint cleared staff members present during the inspection. The facility is in ratio today. The facility was toured for a health and safety inspection. Hours of operation are Monday through Friday, 8AM to 3:15pm.

CLASSROOMS: Three (3) classrooms were inspected. There are adequate play and learning materials available. The floors, furniture, and equipment are age appropriate and in good repair. There is adequate heating/air conditioning, ventilation and lighting and working telephones. Drinking water is available inside and outside of the center. There is proper individual storage space for each child. The isolation area for sick children is the common area, away from other children in care. The center has smoke detectors, carbon monoxide and two fully charged 3A40BC fire extinguishers that was last checked by All Guard on September 20, 2022.There is also an emergency disaster backpack located in the classrooms. Per director, the children will take an hour of nap 4 times a week except Fridays, which it is a minimum day for the children. Blankets and bedding are given to parents every Thursday to clean and are using sleeping mats. The facility last conducted a fire drill was on September 28, 2022.

BATHROOMS AND TOILETING AREAS: The staff's bathroom is separate from the children's bathroom. All sinks and faucets are in safe and sanitary operating condition. The children can reach the sinks and toilets with stepping stools available. Supplies are available to the children. There is also a physical divider between each toilet to provide privacy to each child.

FOOD SERVICE AREAS: There are weekly menus posted at the facility; per director the menu is changed every month. Facility does not provides snacks and lunch; children would bring their own meals and snacks. All storage containers for solid waste have tight fitting covers that are in good repair. SEE LIC 809C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly PhanTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022
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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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: PEACE TERRACE ACADEMY
FACILITY NUMBER: 013417856
VISIT DATE: 10/17/2022
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OUTDOOR PLAY AREAS: There's a play structure with a slide that has cushioning to absorb falls and that is anchored for stability. There's also plenty of trees that provides shade to children while at play. Per director, the right side yard is OFF limits to children. Staff also inspects the play area before any children plays outdoor as the play yard is shared with Sunday school organized by Islamic Society of East Bay (ISEB).

RECORDS: All individuals subject to criminal record review have a clearance or exemption and have been associated to the facility. Six (6) children's files were reviewed around 10:15 AM and found to be complete. Five (5) staff files were also reviewed and found that there were several documents missing either MMR (Measles, Mumps, and Rubella) or Pertussis along with LIC 508 (Criminal Statement), LIC 503 (Health Screening form), and LIC 9052 (Employee Rights). Facility director has CPR and First aid card valid from 11/28/2020 to 11/28/2022. The center is in compliance with the sign in and out procedure as there were 22 signatures for 22 children present. All required documents are posted in a public accessible area. per director, the facility is not using their waivers of outdoor play and shared bathroom use, it was only utilized during COVID. Facility roster was reviewed and obtained.

HEALTH RELATED SERVICES: LPA observed and reviewed 1 child's documents including LIC 9221 (Parent's Consent) in the classroom that shows that how the child's medication are being stored at the facility; all medications have original containers and are not expired. The center is equipped with a fully stocked first aid kit that is available in the classroom. Director was reminded to have an IMS (Incidental Medical Service) plan in place.

There is 1 deficiency cited today - Type B - There were several documents missing in staff files including either MMR (Measles, Mumps, and Rubella) or Pertussis along with LIC 508 (Criminal Statement), LIC 503 (Health Screening form), and LIC 9052 (Employee Rights). see LIC 809D SEE LIC 809 C

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly PhanTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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: PEACE TERRACE ACADEMY
FACILITY NUMBER: 013417856
VISIT DATE: 10/17/2022
NARRATIVE
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Appeal rights and a notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirement shall result in an immediate civil penalty of $100.00. Exit interview conducted and report was reviewed with the center director, Roohi Qadir

Facility representative 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.

Incidental Medical Services (IMS) policy was discussed. This facility provides IMS to children in care. 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.”


LPA discussed the safe sleep regulations with licensee 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 licensee 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 LIC 809 C

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly PhanTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: PEACE TERRACE ACADEMY
FACILITY NUMBER: 013417856
VISIT DATE: 10/17/2022
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Licensee was reminded that California Law requires licensed Child Care Centers 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 electronic mail. LPA informed the Facility Representative that all forms can be downloaded at www.ccld.ca.gov and encouraged the Facility Representative to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Licensee was also reminded 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.

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.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly PhanTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/10/2022 01:37 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 STE 1102
OAKLAND, CA 94612


FACILITY NAME: PEACE TERRACE ACADEMY
FACILITY NUMBER: 013417856

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as there were some staff files that were missing required vaccines, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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Director would obtain and send proof to LPA by 10/28/2022
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) 622-2631
LICENSING EVALUATOR NAME: Kelly PhanTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5