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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010215033
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:44:58 PM

Document Has Been Signed on 01/09/2024 03:44 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:OAKLAND HEAD START - MANZANITAFACILITY NUMBER:
010215033
ADMINISTRATOR:TERRY CHENFACILITY TYPE:
850
ADDRESS:2701 - 22ND AVENUETELEPHONE:
(510) 535-5627
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 12DATE:
01/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:TERRY CHENTIME COMPLETED:
04:00 PM
NARRATIVE
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On January 9,2024 met with center Terry Chen to discuss a self reported unusual incident that occurred on 12/5/2023 when a staff member was observed holding a child's hands firmly and verbally scolding the child.

Upon arrival there are 12 preschool age children present along with 3 staff, not including the director. Today an interview was conducted with the center director and per director, an informal meeting was held with the staff member and the child's parent. According to the director, re-direction practices were also explained/reiterated as well as practices on how to handle difficult children.

Please see the attached 809-D for citation.

An exit interview was conducted, A notice of site visit was posted.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
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 01/09/2024 03:44 PM - It Cannot Be Edited


Created By: Tasha Hackett-Alexander On 01/09/2024 at 01:01 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: OAKLAND HEAD START - MANZANITA
FACILITY NUMBER: 010215033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2024
Section Cited
CCR
101223(a)(3)

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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY:
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LICENSEE WILL HAVE THE STAFF MEMBER TAKE A TRAINING ON HOW TO DEAL WITH CHALLENGING BEHAVIORS OF A CHILD AND PERSONAL FRUSTRATIONS AND SUBMIT A SUMMARY OF WHAT WAS LEARNED TO COMMUNITY CARE LICENSING BY 1/23/24
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 A SELF REPORTED UNUSUAL INCIDENT REPORT AND INTERVIEW WHICH REVEALED A STAFF MEMBER FIRMLY HELD A CHILD'S HANDS AND VERBALLY SCOLDED THE CHILD
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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:Loretta Dyson
LICENSING EVALUATOR NAME:Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
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