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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213003
Report Date: 02/27/2024
Date Signed: 02/27/2024 04:07:45 PM

Document Has Been Signed on 02/27/2024 04:07 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:ALAMEDA ISLAND KIDS AT EDISON SCHOOLFACILITY NUMBER:
010213003
ADMINISTRATOR:NAVARRO, CHRISTINEFACILITY TYPE:
840
ADDRESS:2700 BUENA VISTA AVE.TELEPHONE:
(510) 769-1975
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY: 66TOTAL ENROLLED CHILDREN: 66CENSUS: 50DATE:
02/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH: Angela SmithTIME COMPLETED:
04:15 PM
NARRATIVE
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On 2/27/24, Licensing Program Analyst (LPA) Catherine Fernandes conducted an unannounced case management in regards to a self reported unusual incident sent to the Oakland Regional Office. LPA met with site Director Angela Smith. Present in care was 50 school aged children and four staff members.

On 2/7/2024, an incident was reported by the Director regarding a child (C1) leaving the center and walking home without supervision. As soon as staff was aware of the incident a staff member and the sibling of the child (C2) went to the child's house where C1 was located. LPA informed Director that 100% visual supervision is required in a licensed facility. The facility is in violation of California Code of Regulation, Title 22.

LPA Fernandes informed Director Smith that this report dated 02/27/24 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the safety of children in care. Also, LPA Fernandes informed the Director to provide a copy of this licensing report dated 02/27/24 documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

See 809D for deficiency
Exit interview conducted
Report and Appeal Rights reviewed and provided to Director
The Notice of Site Visit must remain posted
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Catherine Fernandes
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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 02/27/2024 04:07 PM - It Cannot Be Edited


Created By: Catherine Fernandes On 02/27/2024 at 03:29 PM
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: ALAMEDA ISLAND KIDS AT EDISON SCHOOL
FACILITY NUMBER: 010213003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision: No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement has not been met as evidenced by:
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Center will come up with a plan to ensure no child is left without supervision and send the plan to LPA Catherine Fernandes by POC date.

$500 civil penalty has been assessed.
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Based on the self reported incident a child was left without supervision, which is an immediate safety risk 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:Mayla Mendoza
LICENSING EVALUATOR NAME:Catherine Fernandes
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024


LIC809 (FAS) - (06/04)
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