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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421292
Report Date: 11/19/2019
Date Signed: 11/25/2019 02:54:18 PM

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:RAYMOND, DOROTHEAFACILITY NUMBER:
013421292
ADMINISTRATOR:RAYMOND, DOROTHEAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 938-6666
CITY:BERKELEYSTATE: CAZIP CODE:
94706
CAPACITY:14CENSUS: 13DATE:
11/19/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Dorothea RaymondTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts Caroline Colson and Arminder Singh met with Dorothea Raymond, her assistants, Skyla Ernst, Raj Rai and her adult son Theodore Raymond-Navik for an unannounced case management inspection at 11:41 AM. There are 12 preschool children and 1 infant present.

Please see LIC 809 D for deficiency that was cited during today's inspection.

Notice of site visit was posted at the time of the inspection and must be posted for 30 days. An exit interview was conducted. Appeal rights were given and discussed. This report must be available for public review for 3 years.

Original Signatures are on file.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019
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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: RAYMOND, DOROTHEA
FACILITY NUMBER: 013421292
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2019
Section Cited

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Staffing Ratio and Capacity
For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: Twelve children, no more than four of whom mey be infants; or More than twelve and up to fourteen children only if the criteria in Section 1597.465 of the Health and Safety Code are met.
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This requirement was not met as evidenced by document review and licensee interview. This poses a potential health and safety risk to the children in care. There was 12 preschool and 1 infant.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250.00 per violation and $100 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: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2019
LIC809 (FAS) - (06/04)
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