073408290-11-13-2020-02-CC-SJON-BVNRSC-20201124121627

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 073408290
Report Date: 11/13/2020
Date Signed: 11/13/2020 12:27:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Jaylena Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20200819080858

FACILITY NAME:	ST. JOHN'S PRESCHOOL		FACILITY NUMBER:	073408290
ADMINISTRATOR:	SHONECE BARNEY		FACILITY TYPE:	850
ADDRESS:	5555 CLAYTON ROAD		TELEPHONE:	(925) 672-8855
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY:	58	CENSUS: 13	DATE:	11/13/2020
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shonece Barney		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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9

Staff members yells at the children

INVESTIGATION FINDINGS:

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5
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7
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9
10
11
12
13

On 11/13/2020 Licensing Program Analysts (LPAs) Jaylena Miller and Loretta Dyson conducted an unannounced subsequent complaint investigation at the facility. LPAs met with Director Shonece Barney and explained the purpose of today’s inspection. The finding for the above allegation was delivered during the visit.
During the investigation the department completed a physical plant inspection, reviewed facility records, and conducted interviews. LPAs interviews with staff and children determined there was not enough evidence to support that staff yells at children in care. LPA Miller also conducted an interview an with reporting party who indicated that she witnessed staff yell at children. Based on the interviews and information obtained throughout the investigation, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED.
The director was provided a copy of this report and appeal rights, and the signature on this form acknowledges receipts of these rights. An exit interview was conducted with director and Notice of Site visit was provided and posted on the wall.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 14

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Jaylena Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20200819080858

FACILITY NAME:	ST. JOHN'S PRESCHOOL		FACILITY NUMBER:	073408290
ADMINISTRATOR:	SHONECE BARNEY		FACILITY TYPE:	850
ADDRESS:	5555 CLAYTON ROAD		TELEPHONE:	(925) 672-8855
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY:	58	CENSUS: 13	DATE:	11/13/2020
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shonece Barney		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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8
9

Facility failed to accommodate the child

INVESTIGATION FINDINGS:

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9
10
11
12
13

On 11/13/2020 Licensing Program Analysts (LPAs) Jaylena Miller and Loretta Dyson conducted an unannounced subsequent complaint investigation at the facility. LPAs met with Director Shonece Barney and explained the purpose of today’s inspection. The finding for the above allegation was delivered during the visit.
During the course of this investigation at this time, the department conducted a physical plant inspection, reviewed facility records, and conducted interviews. LPAs interviews with staff and children revealed that during outside play time the staff accommodates C1. C1 is verbal and can communicate his needs to staff while on the playground. LPAs observed C1 playing with other children and participating in activities on the playground. LPA Miller conducted an interview with the reporting party who alleges that C1 is left alone not participating with the other children. Based on the interviews and information obtained throughout the investigation, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED.
The director was provided a copy of this report and appeal rights, and the signature on this form acknowledges receipts of these rights. An exit interview was conducted with director and Notice of Site visit was provided and posted on the wall.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 14

Control Number 02-CC-20200819080858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ST. JOHN'S PRESCHOOL	FACILITY NUMBER: 073408290
	VISIT DATE: 11/13/2020

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	The director was provided a copy of this report and appeal rights, and the signature on this form acknowledges receipts of these rights. An exit interview was conducted with director and Notice of Site visit was provided and posted on the wall.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 14

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Jaylena Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20200819080858

FACILITY NAME:	ST. JOHN'S PRESCHOOL		FACILITY NUMBER:	073408290
ADMINISTRATOR:	SHONECE BARNEY		FACILITY TYPE:	850
ADDRESS:	5555 CLAYTON ROAD		TELEPHONE:	(925) 672-8855
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY:	58	CENSUS: 13	DATE:	11/13/2020
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shonece Barney		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
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5
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7
8
9

Facility is operating out of ratio

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 11/13/2020 Licensing Program Analysts (LPAs) Jaylena Miller and Loretta Dyson conducted an unannounced subsequent complaint investigation at the facility. LPAs met with Director Shonece Barney and explained the purpose of today’s inspection. The finding for the above allegation was delivered during the visit.
During the investigation the department conducted a physical plant inspection, reviewed facility records, and conducted interviews. During LPAs record review it revealed that an incident occurred where a parent dropped off two kids at 6:30am with S3 who was a volunteer at the time, and no other qualified teacher was present at the time of drop off. Based on LPAs observation and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is to be SUBSTSNTIATED. As a result, and per California Code of Regulations, Title 22, Division 12, Chapter 1 Section 101229(a)(1) is being cited.
The director must post this report for thirty days. The director must give each parent of the children in care and future parents of newly enrolled children, for the next one year following today’s date, a copy of this report.
see 9099-C for continuance

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 14

Control Number 02-CC-20200819080858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ST. JOHN'S PRESCHOOL	FACILITY NUMBER: 073408290
	VISIT DATE: 11/13/2020

NARRATIVE

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32

Parents are to sign an LIC 9224- Acknowledgment of Receipt of Licensing reports and this form shall be placed in each child’s file. Failure to post report and or provide a copy of this report to parent’s/authorized guardians can result in additional monetary assessments to the facility.
This report must remain on file for three years. The director was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. Notice of site visit was provided and must be posted for 30 days. Exit interview conducted with director, Shonece Barney.

Please see LIC 9099-D for deficiency cited

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

LIC9099 (FAS) - (06/04)

Page: 5 of 14

Control Number 02-CC-20200819080858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ST. JOHN'S PRESCHOOL	FACILITY NUMBER: 073408290
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/13/2020 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	101229(a)(1) Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time, except as specified in... Supervision shall include visual observation. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Dierctor will come up with a teacher work schedule to make sure a qualified teacher is present at all times during the presence of children and submit to LPA by 11/16/2020.
	8 9 10 11 12 13 14	Based on observation, interviews and record review the facility failed to ensure a qualified a teacher was present during drop off which poses an immediate risk to health and safety to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

LIC9099 (FAS) - (06/04)

Page: 6 of 14

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Jaylena Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20200819080858

FACILITY NAME:	ST. JOHN'S PRESCHOOL		FACILITY NUMBER:	073408290
ADMINISTRATOR:	SHONECE BARNEY		FACILITY TYPE:	850
ADDRESS:	5555 CLAYTON ROAD		TELEPHONE:	(925) 672-8855
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY:	58	CENSUS: 13	DATE:	11/13/2020
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shonece Barney		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility failed to provide a safe environment for the children

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 11/13/2020 Licensing Program Analysts (LPAs) Jaylena Miller and Loretta Dyson conducted an unannounced subsequent complaint investigation at the facility. LPAs met with Director Shonece Barney and explained the purpose of today’s inspection. The finding for the above allegation was delivered during the visit.

During the investigation the department conducted a physical plant inspection, reviewed facility records, and conducted interviews. LPAs observed padding from the cement walkway to the gate of the playground to act as a pathway. The pathway from the gate to the blacktop is surrounded by tan bark. Although the facility may have failed to provide a safe environment for C1 at the time of the alleged complaint, during the course of this investigation LPAs did not observe an unsafe environment for C1 as he was assisted the entire time by S2 and was fully able to communicate his wants and needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 7 of 14

Control Number 02-CC-20200819080858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ST. JOHN'S PRESCHOOL	FACILITY NUMBER: 073408290
	VISIT DATE: 11/13/2020

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	The director was provided a copy of this report and appeal rights, and the signature on this form acknowledges receipts of these rights. An exit interview was conducted with director and Notice of Site visit was provided and posted on the wall.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

LIC9099 (FAS) - (06/04)

Page: 8 of 14

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Jaylena Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20200819080858

FACILITY NAME:	ST. JOHN'S PRESCHOOL		FACILITY NUMBER:	073408290
ADMINISTRATOR:	SHONECE BARNEY		FACILITY TYPE:	850
ADDRESS:	5555 CLAYTON ROAD		TELEPHONE:	(925) 672-8855
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY:	58	CENSUS: 13	DATE:	11/13/2020
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shonece Barney		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
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3
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5
6
7
8
9

Children allowed in off limits areas

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 11/13/2020 Licensing Program Analysts (LPAs) Jaylena Miller and Loretta Dyson conducted an unannounced subsequent complaint investigation at the facility. LPAs met with Director Shonece Barney and explained the purpose of today’s inspection. The finding for the above allegation was delivered during the visit.
During the investigation the department conducted a physical plant inspection, reviewed facility records, and conducted interviews. LPAs conducted a physical inspection of the parish hall that the facility was using for outdoor play due to the poor air qualities caused by the fires. LPAs observed an open doorway that leads to the kitchen, but no children were present. Per the director the children to do not go into the kitchen for any reason. The director indicated that she understands the kitchen is off limits and should be made inaccessible to children in care by child safety gates, barriers, locked doors or 100% visiual supervision. LPA Miller interviewed the reporting party who indicated that children have been in off limit areas. Based on the interviews and information obtained throughout the investigation, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 9 of 14

Control Number 02-CC-20200819080858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ST. JOHN'S PRESCHOOL	FACILITY NUMBER: 073408290
	VISIT DATE: 11/13/2020

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	The director was provided a copy of this report and appeal rights, and the signature on this form acknowledges receipts of these rights. An exit interview was conducted with director and Notice of Site visit was provided and posted on the wall.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

LIC9099 (FAS) - (06/04)

Page: 10 of 14

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/19/2020 and conducted by Evaluator Jaylena Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 02-CC-20200819080858

FACILITY NAME:	ST. JOHN'S PRESCHOOL		FACILITY NUMBER:	073408290
ADMINISTRATOR:	SHONECE BARNEY		FACILITY TYPE:	850
ADDRESS:	5555 CLAYTON ROAD		TELEPHONE:	(925) 672-8855
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY:	58	CENSUS: 13	DATE:	11/13/2020
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shonece Barney		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff engaged in a verbal altercation in the presence of children

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 13 of 14

Control Number 02-CC-20200819080858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ST. JOHN'S PRESCHOOL	FACILITY NUMBER: 073408290
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/13/2020 Section Cited CCR 101223(a)(1)	1 2 3 4 5 6 7	101223(a)(1) Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Facility staff will watch a video on CCLs website on Children's Personal Rights in Child Care and submit a written summary to LPA by 11/27/2020.
	8 9 10 11 12 13 14	Based on observation, interviews and record review the facility failed to ensure the children were not exposed to volatile situation when staff engaged in verbal altercation infront of children which poses a potential risk to the health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jaylena Miller	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020

LIC9099 (FAS) - (06/04)

Page: 14 of 14