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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422266
Report Date: 07/01/2022
Date Signed: 07/01/2022 10:15:13 AM


Document Has Been Signed on 07/01/2022 10:15 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, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:ANDERS, AKIVAFACILITY NUMBER:
013422266
ADMINISTRATOR:ANDERS, AKIVAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 332-9885
CITY:BERKELEYSTATE: CAZIP CODE:
94702
CAPACITY:14CENSUS: DATE:
07/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Akiva AndersTIME COMPLETED:
10:20 AM
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 July 1, 2022 at 8:34am Licensing program Analyst (LPA) Indira Loza arrived at the facility to conduct an annual random inspection. Present for the inspection were the Licensee, and Licensee's daughter, There were no daycare children present during today's inspection. The home was inspected to conduct a Health and Safety check. Operating hours are Monday through Thursday 8:00am to 5:30pm.

The home is a one story home. The home consists of a living room, dining room, kitchen, two bedrooms, one bathroom, unfenced front yard, fenced back yard and converted garage. The converted garage is used for a play room and is the main area of the day care. Licensee states there are no firearms. The isolation area is the living room. The on-limit areas are the entire home except for the first bedroom on the right from the dining room, and the backyard along with the converted garage. There are no pools, spas, hot tubs, fish ponds or similar bodies of water. All poisons, detergents, cleaning compounds and medications are stored in areas which are inaccessible to children. There are no fireplaces or open face heaters accessible to children. The home has a 2A10BC fire extinguisher and a combination smoke and carbon monoxide detector. The converted garage also has a working combined smoke and carbon monoxide detector, as well as a 2A10BC fully charged fire extinguisher.

The Licensee’s Pediatric CPR and First Aid training has been completed and expires June 18, 2024. LPA obtained the children’s files for review and the children's roster. Last Fire Drill was conducted June 20, 2022. The provider provides lunch and snacks for the children.

Licensee was reminded that California Law requires Licensee to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all
*****************************************Report Continues on LIC 809-C**********************************************
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
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 3


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: ANDERS, AKIVA
FACILITY NUMBER: 013422266
VISIT DATE: 07/01/2022
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
26
27
28
29
30
31
32
staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02 CCP. When any IMS is provided, a Plan for Providing 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on
on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

There were no deficiencies cited during today's visit. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Akiva Anders.
SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Indira LozaTELEPHONE: 510-368-3672
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3