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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013418519
Report Date: 01/04/2023
Date Signed: 01/04/2023 11:12:03 AM


Document Has Been Signed on 01/04/2023 11:12 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:PALASTI, ADRIENNE EFACILITY NUMBER:
013418519
ADMINISTRATOR:PALASTI, ADRIENNE EFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 427-2351
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:14CENSUS: 0DATE:
01/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Adrienne PalastiTIME COMPLETED:
09:45 AM
NARRATIVE
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On January 4, 2022 Licensing Program Analyst (LPA) Russ Haderer arrived unannounced at 8:50am to follow up on a complaint received on November 4, 2022. At that time some deficiencies were noted incorrectly on the complaint forms, however, should have been filed on a case management report. This report, and the deficiencies replace those recorded on 11/10/2022.

On arrival, licensee was not at home, her assistant Jasmin Pena was present, there were no children in care. During the visit, 3 children arrived. Licensee returned to facility at 9:10am with her infant child.

At the original visit, licensee did not have the required files for one child in care including all the documentation signed by the parents. These included the LIC700 Child Identification; LIC627 Consent for medical treatment; LIC995A Parents Rights; and child's immunization records. See LIC809D for deficiencies. During the case management visit on 1/04/2023 all required documents for the child were complete and in good order. Deficiencies were cleared this day.

The complaint investigation was continued and documented on the LIC9099 form.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 01/04/2023 11:12 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: PALASTI, ADRIENNE E
FACILITY NUMBER: 013418519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2022
Section Cited

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102417 Operation of a Family Child Care Home
(g)(7) An emergency information card shall be maintained for each child... and the parent's authorization for the licensee or registrant to consent to emergency medical care.
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Licensee to have parent complete required LIC627 Consent for Medical Treatment form for their child and keep a copy in the child's file.
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Based on record review, the licensee did not comply with this requirement as there was no file for one child in care which poses a potential Health and Safety risk to children in care.
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Type B
11/25/2022
Section Cited

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102418 Immunizations
(h)(1)The family day care home shall record each pupil's immunization on the California School Immunization Record, PM 286 (6/95).
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Licensee to have parent provide all immunization records for their child and keep copies in the child's file.
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Based on record review, the licensee did not comply with this requirement as there were no records of any immunization's for one child in care 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: 01/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 01/04/2023 11:12 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: PALASTI, ADRIENNE E
FACILITY NUMBER: 013418519

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2022
Section Cited

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102421 Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7).
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Licensee to have parent complete required emergency identification form for their child and keep a copy in the child's file..
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Based on record review, the licensee did not comply with this requirement as there was no file for one child in care which poses a potential Health and Safety risk to children in care.
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Type B
11/11/2022
Section Cited

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102419 Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parents’ Rights LIC 995A...
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Licensee to have parent complete receipt of required LIC995A Parent's Rights form for their child and retain a copy in the file.
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Based on record review, the licensee did not comply with this requirement as there was no file for one child in care 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: 01/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
LIC809 (FAS) - (06/04)
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