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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408229
Report Date: 08/19/2019
Date Signed: 08/19/2019 02:21:52 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:GAN B'NAI SHALOM AT CONGREGATION B'NAI SHALOMFACILITY NUMBER:
073408229
ADMINISTRATOR:MEDWIN, MARLAFACILITY TYPE:
830
ADDRESS:74 ECKLEY LANETELEPHONE:
(925) 933-7633
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:10CENSUS: 0DATE:
08/19/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Marla MedwinTIME COMPLETED:
03:00 PM
NARRATIVE
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3-LPA, Hollie met with Director, M. Medwin, for the purpose of a Random Health and Safety Inspection of the Infant Component of this Combination Center. A tour of the facility was conducted. There are no children present as school does not open for another one week. The licensee understands that children are to be visually supervised at all time they are in care. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are inaccessible during this visit. Furniture and equipment are age appropriate and appear to be in good condition, free from sharp, loose, pointed parts or small choking articles. The surface of the outdoor activity space is free of hazards. All storage containers for solid waste, (garbage bins) have tight fitting covers that are kept on and in good repair. There is cushioning material under moveable play structures. There is no evidence of insects, vermin or rodents. The facility has age-appropriate furniture and equipment such as cots/mats, changing tables and feeding chairs. The licensee is aware that baby walkers, bouncers, exersaucers and jumpers are not allowed in licensed care. The facility has sufficient infant napping equipment that meets Title 22 Regulation 101439.1(a)-(f). The facility has indoor space for infants that are physically separate from space used by the preschool or school age components. The child care center appears to be in good condition that ensures the safety and well-being of children, employees and visitors. SEE NEXT PAGE FOR CONTINUED REPORT
SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2019
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 5
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: GAN B'NAI SHALOM AT CONGREGATION B'NAI SHALOM
FACILITY NUMBER: 073408229
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2019
Section Cited
CCR
101219b6
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ADMISSION AGREEMENT 101219b6 Admission agreements shall specify the following: (6) Right of the Department to perform the duties authorized in Sections 101200(b) and (c).THIS REQUIREMENT IS NOT BEING MET

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The licensee will update the Admission agreement so that parents are informed of the Rights of LIcensing and Licensing Inspection Authority as it relates to children in Licensed Care and send copy of updated Admissions Agreement to LPA no later than 08-26-19.
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The facility has updated their Admission Agreement has not informed the parents of the Rights of Licensing.
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Type B
08/26/2019
Section Cited
CCR
101419.2
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NEEDS AND SERVICES PLANS 101419.2 Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant. (1) Such plan shall be completed with the assistance of the infant's authorized representative at the personal interview specified in Section 101218.1. THIS REQUIREMENT IS NOT BEING MET
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The Licensee will ensure that all infants have Needs and Services Plans completed before they start the new year. The licensee will send three completed Needs and Services Plan to LPA.
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There are no infant Needs and Services Plans in file for children, thus being a potential hazard to children that would be in care in the future.
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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: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: GAN B'NAI SHALOM AT CONGREGATION B'NAI SHALOM
FACILITY NUMBER: 073408229
VISIT DATE: 08/19/2019
NARRATIVE
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Licensee was reminded that anyone employed at the facilty, must be fingerprint cleared prior to being in the presence of children, or an immediate civil penalty can be assessed. Also discussed during the visit was the following: nutrition education; the new appeal process and documents to be provided to parents/legal guardians. Licensee was encouraged to frequently visit our website at WWW.CC.D.CA.GOV for licensing regulations and updates, particularly Provider Information Notices also known as PINS.

Notice of site visit was posted at the time of the inspection and must remain posted for 30 days.

SEE 809-D FOR TYPE B DEFICIENCIES RELATED TO MANDATED REPORTER TRAINING, NEEDS AND SERVICES PLAN AND ADMISSION AGREEMENTS REGARDING THE RIGHTS OF LICENSING.

THE LICENSEE WAS PROVIDED A COPY OF THEIR APPEAL RIGHTS (LIC 9058 12/15) AND THEIR SIGNATURE ON THIS FORM ACKNOWLEDGES RECEIPT OF THESE RIGHTS.

SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: GAN B'NAI SHALOM AT CONGREGATION B'NAI SHALOM
FACILITY NUMBER: 073408229
VISIT DATE: 08/19/2019
NARRATIVE
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The child care center appears to be in good condition that ensures the safety and well-being of children, employees and visitors. The facility has a functioning carbon monoxide detector in each room. The licensee understands that bottles, dishes and containers of food brought by the infants authorized representative are labeled with the infants name and current date. While in use, the infant changing tables are placed within arms reach of a sink.

The facility is aware that ratio compliance for infants is 1:4.

The facility is aware that all person’s 18 years of age or older, must be fingerprint cleared or associated to the facility, PRIOR to being in the presence of children.

The licensee did not provide IMS (Incidental Medical Services) during the last school seasonal The licensee was encouraged to log onto to our website at CCLD.CA.GOV for the details of what is required if the licensee cares for children who require Epi Pens, Inhalers and Glucose Monitoring.

A sampling of infants files were reviewed and the Infant teacher file was reviewed during this visit.

The Licensee was made aware of Safe Sleep Regulation Concepts as it relates to Infants. During the visit, the Licensee was given a copy of the document containing the Sleep Regulation Concepts.

PLEASE SEE NEXT PAGE FOR CONTINUED REPORT.

SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: GAN B'NAI SHALOM AT CONGREGATION B'NAI SHALOM
FACILITY NUMBER: 073408229
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2019
Section Cited
HSC
1596.8662b1
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HEALTH AND SAFETY 1596.8662b1 On or before March 30, 2018 a person who on January 1, 2018 is a licensed child care provider, administrator or employee of a licensed child day care shall complete the mandated reporter training. THIS REQUIREMENT HAS NOT BEEN MET.
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The Director and staff will complete the training no later than August 30 and mail copies to LPA.
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The Director, nor any of the facility staff have completed the Mandated Reporter Training. Not completing the training, could cause potential harm to children in care.
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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: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5