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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402041
Report Date: 11/17/2021
Date Signed: 11/17/2021 11:48:45 AM

Document Has Been Signed on 11/17/2021 11:48 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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
073402041
ADMINISTRATOR:KLOBERDANZ, JEANNIEFACILITY TYPE:
850
ADDRESS:6095 MAIN STREETTELEPHONE:
(925) 672-9370
CITY:CLAYTONSTATE: CAZIP CODE:
94517
CAPACITY: 72TOTAL ENROLLED CHILDREN: 56CENSUS: 46DATE:
11/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jeannie KloberdanzTIME COMPLETED:
11:55 AM
NARRATIVE
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On 11/17/21 at 11:00 AM Licensing Program Analyst (LPA) Michelle Sutton conducted an unannounced Case Management inspection about an unusual incident self reported by the Center about a child left behind in the playground. LPA met with director Jeannie Kloberdanz and explained the purpose of today's inspection.

LPA conducted interview with director, observed facility, reviewed Personnel Report and Children's Roster. It was determined that a child wondered off alone to the play yard while teachers were inside the facility. Facility is being cited Type A for lack of supervision (see 809-D page).

Due to the issuance of Type A, this report has to be provided to all parents of currently and future enrolled over next 12 months. Report and deficiency page also to be posted in public view. A copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports to be signed by parent and kept in child file.

Exit Interview was conducted, where this report, deficiency and appeal rights was reviewed and discussed with the director Jeannie Kloberdanz. A notice of site visit was given and must remain posted for 30 days.
Sherelle Johnson
Michelle Sutton
DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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 11/17/2021 11:48 AM - It Cannot Be Edited


Created By: Michelle Sutton On 11/17/2021 at 11:23 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 073402041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2021
Section Cited

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101229 Responsibility for Providing Care & Supervision (a) The licensee shall provide care and supervision [..](1) No child(ren) shall be left without the supervision of a teacher at any time[..]. This requirement is not met as evidenced by:
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Based on observation and interview director confirmed that a child wondered off alone to the play yard while teachers were inside facility. This is an immediate risk to Health and Safety or Personal Rights risk to persons in care.
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Site Supervisor will submit proof of staff meeting (sign-in sheet and agenda)

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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Michelle Sutton
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021


LIC809 (FAS) - (06/04)
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