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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422740
Report Date: 08/16/2023
Date Signed: 08/16/2023 01:15:31 PM


Document Has Been Signed on 08/16/2023 01:15 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:BERGENDAHL, S. ANNETTEFACILITY NUMBER:
013422740
ADMINISTRATOR:BERGENDAHL, S. ANNETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 304-9570
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:14CENSUS: 8DATE:
08/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Annette BergendahlTIME COMPLETED:
01:20 PM
NARRATIVE
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On August 16, 2022 at approximately 8:30am Licensing Program Analysts (LPAs) Russ Haderer and Randall Dunevant arrived unannounced for an annual inspection for health and safety. Present for the inspection was the licensee Annette Bergendahl, two fingerprint cleared assistants and 8 children (4 infants; 2 two-years old;2 four-years old; , the home is in ratio today. The hours of operation remain Monday-Friday, 7:00 AM to 6:00 PM.

The facility is a 3-bedroom, two bath single story home with an attached 2-car garage. It is rented by the licensee and contains a living room, dining room, kitchen, 3 bedrooms (including master bath), enclosed (fenced) backyard play area. There is a screened fireplace in the living room. The home is neat and clean with heating and ventilation for safety and comfort. Per the licensee, the ISOLATION AREA will be in middle bedroom next to the house bathroom away from the other children in care.



On-limit include: Kitchen, dining room, living room, daycare room (1st bedroom to right in hallway), hallway bathroom, backyard. master bedroom and middle bedroom (next to the house bathroom bedroom) only used for napping infants in cribs. Licensee was reminded that other than wipes or things used for the children in the on limits children’s bathroom, they need to be empty of most all items (or locked up) such as cleaning products. There are no accessible hazardous cleaning chemicals or other liquids in the on-limits area.

Off-limits include: Attached 2-car garage, locked shed and locked storage unit in backyard, both gated side yards and front yard (other than to walk through for drop off and pick up times). Off limit areas are inaccessible by closed and/or locked doors and visual supervision

All licensing documents required to be posted in a public place were present behind the front entry door
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Randall DunevantTELEPHONE: (510) 725-2063
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: BERGENDAHL, S. ANNETTE
FACILITY NUMBER: 013422740
VISIT DATE: 08/16/2023
NARRATIVE
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Licensee has ample age-appropriate toys and learning materials in the home. There is a fully charged fire extinguisher 3A40BC (inspected 9-19-2022). There is a working smoke and carbon monoxide detector (tested and functioning), and a working telephone. Disaster drills are conducted monthly, the last drill completed 7-06-2022. Licensee has a first aid kit in the main house bathroom. Licensee has a covered barbecue in the backyard.

Per licensee, there are no firearms in the home. LPA did not observe any bodies of water, hazardous materials, or toxins accessible to children on the premises during the inspection. The backyard play area has age appropriate toys and playhouse structures with a patio and grass area. Licensee has three adult dogs kept in dog cages most of the day (per licensee vaccinations are up to date).

The Licensee’s Health and Safety training is completed, however CPR and First Aid certificate is expired see LIC 809D for deficency. The licensees mandated reporter training is expired see LIC 809D for deficiency. The two assistants completed and current Mandated Reporter training, one has current CPR and aid certificate. The licensee and two assistants are compliant with the immunization laws which pertains to day care providers however two assistants have no record of negative TB test see LIC 809D for deficiency.

LPA reminded the licensee of the following; Mandated Reporter training is to be renewed every two years, CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.



Children’s files reviewed and found to be mostly complete. Infant Safe Sleep Plan LIC 9227 is missing for two infant children in care - see LIC 809D for deficiency. Sleep logs for infants to document 15-minute checks have not been maintained. Licensee reminded that documented sleep logs are required and must be completed for all infants from age birth to 24 months see LIC 809D for deficiency. Licensee does not carry liability insurance, children’s files contained signed acknowledgement forms from parents.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Randall DunevantTELEPHONE: (510) 725-2063
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: BERGENDAHL, S. ANNETTE
FACILITY NUMBER: 013422740
VISIT DATE: 08/16/2023
NARRATIVE
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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.

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: https://www.ada.gov/resources/child-care-centers/.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://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 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.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, licensee confirmed that there are no Registered Sex Offenders living in the facility.A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Randall DunevantTELEPHONE: (510) 725-2063
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2023 01:15 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: BERGENDAHL, S. ANNETTE
FACILITY NUMBER: 013422740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that no sleep logs are being used to document infants safe sleep, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee will begin using and documenting sleep logs for all infants in care effective immediately. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in the licensees Mandated reporter certificate expired Nov 2022 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee will renew Mandated reporter training today.
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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Randall DunevantTELEPHONE: (510) 725-2063
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 08/16/2023 01:15 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: BERGENDAHL, S. ANNETTE
FACILITY NUMBER: 013422740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that two staff members could not provide proof of TB test which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Staff members will have TB tests completed within seven days.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that licensee CPR and first aid certificate expired in June 2023 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2023
Plan of Correction
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Licensee has an injured leg and can not drive to attend CPR training. One staff has current CPR training and will remain on site any time children are in care.
Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation per day until corrected.
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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Randall DunevantTELEPHONE: (510) 725-2063
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2023 01:15 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: BERGENDAHL, S. ANNETTE
FACILITY NUMBER: 013422740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101425(c)
101425(c) An Individual Sleeping Plan {LIC9227 (3/20)} shall be completed for each infant up to 12 month of age the provider has in care and mianatined at the facilty in the infants file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that LIC9227 Infant Safe Sleep Plan was not completed and available in the child's file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Licensee will have parents complete sign and date the forms and keep them in the child's file going forward.
Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violations and $100 per day until corrected.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Randall DunevantTELEPHONE: (510) 725-2063
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 6 of 7


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: BERGENDAHL, S. ANNETTE
FACILITY NUMBER: 013422740
VISIT DATE: 08/16/2023
NARRATIVE
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The following five deficiencies were observed during todays inspection

- Licensee first aid and CPR expired

- Licensee Mandated Reporter Certificate expired

- Staff missing proof of negative TB test

- Infant Safe Sleep Plans where not available

- Safe Sleep logs are not being maintained

See 809D for deficiencies cited today.

Failure to correct will result in a $100 per day civil penalty until corrected. repeat violations are $250 per violation and $100 per day until corrected.

Exit interview conducted and report was reviewed with the licensee Annette Bergendahl

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Randall DunevantTELEPHONE: (510) 725-2063
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
LIC809 (FAS) - (06/04)
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