<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422003
Report Date: 09/28/2022
Date Signed: 09/28/2022 02:30:11 PM


Document Has Been Signed on 09/28/2022 02:30 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 - UNITED NATION CHILD DEVELOPMENT CENTERFACILITY NUMBER:
013422003
ADMINISTRATOR:MANSKER, ANNAFACILITY TYPE:
850
ADDRESS:1025 - 4TH AVETELEPHONE:
(510) 273-1616
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:168CENSUS: DATE:
09/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Michele MeadowsTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/28/2022 Licensing Program Analysts (LPAs) Melissa Domantay and Melissa Guirit conducted an unannounced case management inspection at the facility above in regard to unusual incident that occurred on 9/20/2022 where a child fell riding a tricycle. LPAs met with lead teacher, Michele Meadows. Staff Interviews were conducted with staff that were present during the incident. Staff interviews determined that 3 staff were present supervising children during outdoor play time when incident occurred. First aid was performed with ice pack after injury and staff contacted childs mother after incident occurred.

No deficiencies being cited today.

An exit interview was conducted with Lead Teacher Michele Meadows and report and notice of site was provided. Appeal rights provided.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Melissa DomantayTELEPHONE: 510-725-7021
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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 1