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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422499
Report Date: 09/15/2021
Date Signed: 09/15/2021 04:18:19 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:EAST BAY GERMAN INTERNATIONAL SCHOOLFACILITY NUMBER:
013422499
ADMINISTRATOR:KACHINE BLACKWELLFACILITY TYPE:
850
ADDRESS:1070 41ST STREETTELEPHONE:
(510) 679-2199
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY:44CENSUS: 46DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:TIME COMPLETED:
04:30 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
Licensing Program Manager (LPM) Mayla Mendoza met today 9/15/21 with Director Birgit Rulofs and Licensee/Applicant Rufus Pichler for an annual random inspection. LPM toured the facility and play yard for a health and safety inspection. This facility is on the premises of East Bay German International School.

Personnel files were reviewed. A percentage of children's files were reviewed at 11:00am. The classroom(s) and play yard were age appropriate and in good repair. Bathrooms were clean and in working order. There is a separate staff bathroom. Lunches and snacks are brought from home. The kitchen area was maintained in a clean manner and was inaccessible to children in care. Waste containers have tight fitting lids. The storage of napping equipment was observed. The sign in and out logs were reviewed. Firearms and other weapons are not being stored on the premises. All posting requirements are being met. Outdoor play area was free of hazards and provided a shaded area for the children and access to drinking water. Play ground equipment is cushioned with material that absorbs a fall. There are no bodies of water. The facility has a carbon monoxide detector, charged fire extinguishers and first aid kits. Fire and disaster drills are being conducted monthly. There is a working telephone at the facility. At least one person trained in CPR and Pediatric First Aid is present.

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
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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 9
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: EAST BAY GERMAN INTERNATIONAL SCHOOL
FACILITY NUMBER: 013422499
VISIT DATE: 09/15/2021
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
Director Rulofs was reminded that all adults 18 and over, 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 Child Care Center. 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.

Mandated reporter, appeal rights, civil penalties, unusual incident reporting and zero tolerance were discussed today. The director is also reminded that mandated reporter training is required for all staff and is to be renewed every 2 years at www.mandatedreporterca.com.


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


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

Exit interview conducted and report was reviewed with Director Rulofs.


SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 9
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: EAST BAY GERMAN INTERNATIONAL SCHOOL
FACILITY NUMBER: 013422499
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(d)
Criminal Record Clearance
(d) All individuals subject to criminal record review shall, be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/16/2021
Plan of Correction
1
2
3
4
Samira Noorin will not be allowed to return to facility until she recieves a cleared criminal background check
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 9
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: EAST BAY GERMAN INTERNATIONAL SCHOOL
FACILITY NUMBER: 013422499
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(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.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2021
Plan of Correction
1
2
3
4
Send copies of staff immunizations to LPM Mendoza
Type B
Section Cited
CCR
101216.1(g)
Teacher Qualifications and Duties
(g) A photocopy of the teacher's Child Development Permit as specified in (c)(3) above, or a photocopy of the teacher's transcript(s) documenting successful completion of required course work, shall be maintained at the center.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2021
Plan of Correction
1
2
3
4
Please send copies of transcripts of teachers
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: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Mayla MendozaTELEPHONE: (510) 873-6408
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2021
LIC809 (FAS) - (06/04)
Page: 4 of 9