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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422032
Report Date: 05/15/2024
Date Signed: 05/15/2024 03:17:43 PM


Document Has Been Signed on 05/15/2024 03:17 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:AB'S PRESCHOOL AND DAYCAREFACILITY NUMBER:
013422032
ADMINISTRATOR:AYALEW, MERATFACILITY TYPE:
830
ADDRESS:301 DOWLING BLVDTELEPHONE:
(510) 564-4276
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY:12CENSUS: 4DATE:
05/15/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Gayle Tom Burns and Donna JeffersonTIME COMPLETED:
03:30 PM
NARRATIVE
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On 5/15/2024 at 9:40 am, Licensing Program Analysts (LPAs) Manel Estoesta and Jaleesa Jackson conducted a Plan of Correction (POC) visit. LPAs met with the Lead Teacher Gayle Tom Burns at 10 am and Office Assistant Donna Jefferson at 11:45 am and explained the nature of the visit. At the time of LPA's arrival, present were one Staff for the Infant Component, 2 Staff for the Preschool Component, 4 infants in the Teddy Bear Room and 6 preschool children in the Pre-K room.

LPA Estoesta informed Donna that this report dated 5/15/2024 included a Type A and B Citations which shall be posted for 30 consecutive days as there is an immediate and potential risk to the health, safety, or personal rights of children in care.

See LIC 9099 D for the Repeat Violations of Type A and B from the 4/17/2024 and 5/1/2024 visits, new Type A and B violations, Plan of Corrections (POCs) and Civil Penalties.

Also, LPAs informed Donna to provide a copy of this licensing report dated 5/15/2024 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.



A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Office Assistant, Donna Jefferson.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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 05/15/2024 03:17 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: AB'S PRESCHOOL AND DAYCARE
FACILITY NUMBER: 013422032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2024
Section Cited
CCR
101229.1(a)(1)

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101229.1 Sign In and Sign Out (a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain, and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.....
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LPA advised Donna to complete the requirement below, have the parent to complete the sign in by the end of the day, and submit a copy to the Regional Office.

LPA will endorse the facility for a Non-Compliance Conference (NCC).
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04/17/2024 1st violation and 5/1/2024 2nd violation. This requirement is not met as evidenced by, 3rd violation, LPA's observation at 9:50 am, 1 of 4 infants was not signed in, the licensee did not comply with the section cited above in which poses an immediate risk to the health, safety or personal rights to children in care.
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LPA shall endorse the facility for the Technical Support Program (TSP) is the non-enforcement service of Community Care Licensing to help providers, and to the local Resource and Referral (R&R).
Type A
05/15/2024
Section Cited
CCR101416.5(b)(1)(A)

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101416.5 Staff-Infant Ratio (b) There shall be a ratio of one teacher for every four infants in attendance. (1) An aide may be substituted for a teacher when all of the following conditions are met: (A) There is a fully qualified teacher directly supervising no more than 12 infants; and......
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At 10 am, Staff GAYLE TOMSBURNS, came in to supervise in the Teddy Bear Room with Staff Rgbe.

LPA will endorse the facility for a Non Compliance Conference (NCC).
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04/17/2024 1st violation and 5/1/2024 2nd violation. This requirement is not met as evidenced by, 3rd violation, LPA's observation at 9:50 am, Staff Rgbe was by herself supervising 4 infants at the Infant Room, the licensee did not comply with the section cited above in which poses an immediate risk to the health, safety or personal rights to children in care.
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LPA shall endorse the facility for the Technical Support Program (TSP) is the non-enforcement service of Community Care Licensing to help providers, and to the local Resource and Referral (R&R).
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) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2024 03:17 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: AB'S PRESCHOOL AND DAYCARE
FACILITY NUMBER: 013422032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2024
Section Cited
CCR
101427(j)

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101427 Infant Care Food Service (j) Bottles, dishes and containers of food brought by the infant's authorized representative shall be labeled with the infant's name and the current date.....
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The Licensee shall again develop a plan, in writing, how to manage the Infant Care Food Service in the Facility.

LPA will endorse the facility for a Non Compliance Conference (NCC).
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04/17/2024 1st violation and 5/1/2024 2nd violation. This requirement is not met as evidenced by, 3rd violation, LPA's observation at 10:30 am, Child 3 infant milk bottle in the refrigerator was not labeled with the infant’s name and current date, the licensee did not comply with the section cited above in which poses an immediate risk to the health, safety or personal rights of children in care.
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LPA shall endorse the facility for the Technical Support Program (TSP) is the non-enforcement service of Community Care Licensing to help providers, and to the local Resource and Referral (R&R).
Type B
05/22/2024
Section Cited
CCR101217(a)(11)

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101217 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 101216(g).....
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LPA advised Donna to have Gayle to complete the requirement below and submit a copy to the Regional Office.

LPA will endorse the facility for a Non-Compliance Conference (NCC).
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This requirement is not met as evidenced by, LPA's record review at 11am, Staff Gayle did not the LIC 503 in her file, the licensee did not comply with the section cited above in which poses an potential risk to the health, safety or personal rights of children in care.
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LPA shall endorse the facility for the Technical Support Program (TSP) is the non-enforcement service of Community Care Licensing to help providers, and to the local Resource and Referral (R&R).
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) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/15/2024 03:17 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: AB'S PRESCHOOL AND DAYCARE
FACILITY NUMBER: 013422032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2024
Section Cited
CCR
101170(e)(2)

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101170 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 101170(f)
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LPA advised Donna to complete the LIC 9182 as the requirement below and submit a copy to the Regional Office. LPA provided the information for Guardian.

LPA will endorse the facility for a Non-Compliance Conference (NCC).
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This requirement is not met as evidenced by LPA's record review at noon, Staff Donna has an existing criminal record clearance and was not transferred to this facility, the licensee did not comply with the section cited above in which poses an immediate risk to the health, safety or personal rights of children in care.
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LPA shall endorse the facility for the Technical Support Program (TSP) is the non-enforcement service of Community Care Licensing to help providers, and to the local Resource and Referral (R&R).
Type B
05/22/2024
Section Cited
HSC1596.7995(a)(1)

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1596.7995 Employees or volunteers at day care center; immunization requirements; records; exemptions (a) (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.
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LPA advised Donna to have Gayle to complete the requirement below and submit a copy to the Regional Office.

LPA will endorse the facility for a Non-Compliance Conference (NCC).
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This requirement is not met as evidenced by, LPA's record review at 11am, Staff Gayle did not have MMR and flu vaccination records in her file, the licensee did not comply with the section cited above in which poses a potential risk to the health, safety or personal rights of children in care.
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LPA shall endorse the facility for the Technical Support Program (TSP) is the non-enforcement service of Community Care Licensing to help providers, and to the local Resource and Referral (R&R).
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) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4