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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422038
Report Date: 11/08/2019
Date Signed: 11/08/2019 02:36:47 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:OUR LADY OF GUADALUPE PRESCHOOLFACILITY NUMBER:
013422038
ADMINISTRATOR:ZAVERI, JAVAIKAFACILITY TYPE:
850
ADDRESS:40374 FREMONT BLVDTELEPHONE:
(510) 657-1674
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:22CENSUS: 11DATE:
11/08/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Brigette BrooksTIME COMPLETED:
02:55 PM
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(3) Licensing Program Analysts (LPA) Melanie Otsuji arrived to the facility unannounced to conduct an Annual/Random inspection. LPA was met by Director Brigette Brooks. Present during today's visit were 2 staff members and 11 preschool aged children.

LPAs conducted a health & safety inspection of the facility both indoors and outdoors. There are no bodies of water accessible to children in care. On today's date, 11/8/2019, there is a ratio of one teacher supervising no more than 12 children in attendance. Disinfectants and other dangerous items are kept inaccessible to children in care. All materials and surfaces accessible to children are toxic free. All toilets and hand washing facilities are in safe and sanitary operating conditions. Furniture and equipment are in good condition, free of sharp, loose and pointed parts. All kitchen, food prep and storage areas are clean, free of litter and rubbish. Uncontaminated drinking water is available both indoors and outdoors. Facility has one or more functioning carbon monoxide detectors. Staff records contained the appropriate documentation education credits. At least one person trained in CPR/Pediatric First Aid is present when children are at the facility. The person that signs the child in/out uses their full legal signature and records the time of day. Child's admission agreement is available for review. The child is signed in and out by the person responsible for the child.
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

No deficiencies are being cited during today's visit. An exit interview was conducted. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. This report must be available for public review for 3 years. LPA provided Notice of Site visit and Licensee posted visit notice in LPAs presence.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2019
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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