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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413755
Report Date: 10/07/2022
Date Signed: 10/07/2022 03:23:36 PM


Document Has Been Signed on 10/07/2022 03:23 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:AFTER SCHOOL ADVENTURESFACILITY NUMBER:
434413755
ADMINISTRATOR:NASRIN ZARKUBFACILITY TYPE:
840
ADDRESS:1840 HARRIS AVENUE ROOM #31TELEPHONE:
(408) 264-8400
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:60CENSUS: 39DATE:
10/07/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Nasrin ZarkubTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA), James Santos arrived at the facility today for the continuation of the Required 1 Year inspection. LPA met with Licensee, Nasrin Zarkub.

LPA reviewed five (5) children's files. Children's records reviewed include Admission Agreement, Identification and Emergency Contact, Consent for Emergency Medical Treatment form, Parent Rights Notice and Personal Rights Notice.

Per review of record, the center conducts emergency disaster drills monthly.

Licensee 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.

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

No deficiencies cited. Exit interview conducted and report was reviewed and a copy was provided with Licensee, Nasrin Zarkub.




NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: James G SantosTELEPHONE: (408) 334-8556
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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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