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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010214925
Report Date: 11/28/2023
Date Signed: 11/28/2023 01:17:27 PM


Document Has Been Signed on 11/28/2023 01:17 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:ADVENTURE TIME - ARDENWOODFACILITY NUMBER:
010214925
ADMINISTRATOR:GONZALEZ, YESSICAFACILITY TYPE:
840
ADDRESS:33955 EMILIA LANETELEPHONE:
(510) 797-6280
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY:115CENSUS: 6DATE:
11/28/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Luigi BozzoTIME COMPLETED:
01:30 PM
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On 11/28/2023 at 10:15AM, Licensing Program Analyst (LPA) Jaleesa Jackson met with Luigi Bozzo for an Unannounced Required Inspection. Present for this inspection are 6 school aged children and 1 fingerprint cleared staff member. Facility operating hours are 7:00AM to 6:00PM Monday - Friday. The facility was toured to conduct a health and safety inspection.

At 10:20AM, LPA toured the facility classroom. The facility is utilizing a portable on the site of Ardenwood Elementary School. The classroom is tidy and clean with heating and ventilation for safety and comfort. There are safe age-appropriate toys and learning materials available to children throughout the classroom. Each child has individualized space for their personal belongings. All hazardous materials and toxins including disinfectants and cleaning solutions were observed to be made inaccessible to children during today's inspection. The facility provides filtered drinking water with disposable cups or ask children to bring their own water bottles to be used inside and outside the facility. LPA reviewed storage and documentation of children's medications; all medications are made inaccessible to children are in a locked cabinet and medications are in original containers with unaltered instructions and are not expired. There are two fully charged fire extinguishers and smoke detectors. There is also a working carbon monoxide detector and working telephones in the class. All required forms are posted in public view. Children are able to bring their own food or will have provided meals from the elementary school.

The play structures was observed to be operable and age-appropriate during this inspection. The playground is shared with other children of Ardenwood Elementary School. Areas around slides and high climbing equipment have wood chips to absorb any falls. There are also plenty of trees to provide shade. There are no pools, hot tubs, ponds, or any other bodies of water accessible to children.

Continued on 809-C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Jaleesa JacksonTELEPHONE: (510) 368-0021
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ADVENTURE TIME - ARDENWOOD
FACILITY NUMBER: 010214925
VISIT DATE: 11/28/2023
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At 11:00AM, LPA reviewed 7 staff files and 5 children file. LPA also reviewed the sign in/out sheet and found that all children were signed in. There is at least one staff on site with valid CPR and first aid. Disaster drills are conducted at least every 6 months. The last drill was 10/19/2023.

There was one deficiency cited on today's visit. See 809-D.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.



For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP).

LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.



This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records.

Continued on 809-C

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Jaleesa JacksonTELEPHONE: (510) 368-0021
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ADVENTURE TIME - ARDENWOOD
FACILITY NUMBER: 010214925
VISIT DATE: 11/28/2023
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For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care- centers/.

Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative Luigi Bozzo.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Jaleesa JacksonTELEPHONE: (510) 368-0021
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 11/28/2023 01:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: ADVENTURE TIME - ARDENWOOD
FACILITY NUMBER: 010214925

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 7 staff did not have a LIC503 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2023
Plan of Correction
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Director must send completed LIC503 for the two missing staff members by POC due date to LPA by email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jason JangTELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Jaleesa JacksonTELEPHONE: (510) 368-0021
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
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