010214925-9-6-2023-52-CC-MOTI-CVET2P-20230906142105

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 010214925
Report Date: 09/06/2023
Date Signed: 09/06/2023 02:21:27 PM

Document Has Been Signed on 09/06/2023 02:21 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME:	ADVENTURE TIME - ARDENWOOD		FACILITY NUMBER:	010214925
ADMINISTRATOR:	GONZALEZ, YESSICA		FACILITY TYPE:	840
ADDRESS:	33955 EMILIA LANE		TELEPHONE:	(510) 797-6280
CITY:	FREMONT	STATE: CA	ZIP CODE:	94555
CAPACITY:	90	CENSUS: 79	DATE:	09/06/2023
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Jayjay Nagayo		TIME COMPLETED:	02:40 PM

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	A Case Management Inspection was conducted on this date 09/06/2023 at 1:30PM by Licensing Program Analyst (LPA) Melanie Otsuji. LPA met with Facility Representative, Jayjay Nagayo. An application was submitted for a Capacity Increase and Room Addition. Facility is requesting to increase from 90 school aged children to 115 school aged children. The school age program is located on Ardenwood Elementary School campus. The program is currently utilizing the Adventure Time portable. Facility is requesting to add the Multi-Purpose Room. Hours of operation are from 7:00AM - 6PM (Mon-Fri). Also present during today's visit were 6 additional staff members and 79 school aged children. A health and safety inspection was conducted inside and outside. INDOORS: EXEMPT OUTDOORS: EXEMPT This facility is exempt from square footage and bathroom requirements. Facility utilizes the Elementary School playground, blacktop and grassy area. Facility understands that at no time should the Adventure Time children commingle with the Elementary School children. Drinking water is available inside and outside by way of water fountains and bottles brought from home. Facility provides AM/PM snacks. Menus are posted. Facility has a functioning carbon monoxide detector, smoke detector and fire extinguisher. Facility has a sign in/out sheet that allows ample space for full legal signature and records time and date. An approved Fire Clearance was received on 08/15/2023 from Fremont Fire Department for 115 school aged children.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Melanie Otsuji	TELEPHONE: (510) 622-2613
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

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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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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: ADVENTURE TIME - ARDENWOOD	FACILITY NUMBER: 010214925
	VISIT DATE: 09/06/2023

NARRATIVE

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All licensing required documents are posted. Per facility representative, all Opening and Closing staff have current Pediatric CPR/First Aid. This facility plans to provide Incidental Medical Services – IMS. An updated Plan of Operation that includes IMS must be submitted to the Department when any changes are made. 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.

The center was found to be clean, safe, sanitary and in good repair.

There are no deficiencies cited during today's visit. A license with approval for 115 school aged children operating out of the Adventure Time Portable and Multi-Purpose Room will be issued effective, 9/6/2023.

An exit interview was conducted with facility representative, Jayjay Nagayo.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Melanie Otsuji	TELEPHONE: (510) 622-2613
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023

LIC809 (FAS) - (06/04)

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