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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013418180
Report Date: 08/24/2022
Date Signed: 08/24/2022 03:55:02 PM


Document Has Been Signed on 08/24/2022 03:55 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:OUSD - ACORN/WOODLANDFACILITY NUMBER:
013418180
ADMINISTRATOR:VASQUEZ, LINDAFACILITY TYPE:
850
ADDRESS:1025 EIGHTY FIRST AVENUETELEPHONE:
(510) 879-0197
CITY:OAKLANDSTATE: CAZIP CODE:
94621
CAPACITY:48CENSUS: 14DATE:
08/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Caroline JonesTIME COMPLETED:
04:08 PM
NARRATIVE
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On Wednesday, August 24, 2022 at 1:30 PM, Licensing Program Analyst (LPA) Caroline Colson met with Caroline Jones, Site Administrator, for an unannounced case management inspection. There are 14 preschool children present and 6 staff members including two teachers. An incident occurred where a child left the preschool playground during dismissal. The teachers in charge were not aware that a child was missing from the preschool until the child was returned by another family who located her off campus.

The attached type A deficiency is cited today and must be corrected by the due date. An exit interview was conducted. Upon receipt, licensee shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Appeal rights were given and discussed. A site visit notice was posted.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
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 08/24/2022 03:55 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: OUSD - ACORN/WOODLAND
FACILITY NUMBER: 013418180

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2022
Section Cited

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Responsibility for Care and Supervision
No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Based on record review, the licensee did not comply with the section cited above because a child was able to leave the facility without adult supervision which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct will result in a $100.00 per day civil penalty until corrected. Repeat violations are 250.00 per violation and $100.00 per day until corrected.

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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: Mayla MendozaTELEPHONE: (510) 292-2724
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 725-7008
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2022
LIC809 (FAS) - (06/04)
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