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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412413
Report Date: 07/26/2023
Date Signed: 07/26/2023 10:50:55 AM


Document Has Been Signed on 07/26/2023 10:50 AM - 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 EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:EXTENDED DAY CHILD CARE - DUBLIN ELEMENTARYFACILITY NUMBER:
013412413
ADMINISTRATOR:SINCLAIR, VANESSAFACILITY TYPE:
840
ADDRESS:7997 VOMAC ROADTELEPHONE:
(925) 551-8170
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY:150CENSUS: 55DATE:
07/26/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Facility in charge Amy BolenderTIME COMPLETED:
11:15 AM
NARRATIVE
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On Wednesday, 07/26/2023, at approximately 9:25 AM, Licensing Program Analyst Jyoti Saini conducted an unannounced collateral visit and met with the person in charge, Amy Bolender, of EDCC Dublin Elementary at the Fredrickson Elementary campus. The facility in charge acknowledged that since the primary location is under construction by the district , EDCC Dublin is temporarily running the summer program at Fredrickson Elementary's MPR room however did not notify the Community Care Licensing Division (CCLD). Since the facility failed to report to the Community care licensing division (CCLD) about the temporary relocation, it violated the regulations.

See the attached LIC809-D for deficiency.

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

Exit interview conducted and report was reviewed with facility in charge Amy Bolender. .

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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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Document Has Been Signed on 07/26/2023 10:50 AM - 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 EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612


FACILITY NAME: EXTENDED DAY CHILD CARE - DUBLIN ELEMENTARY
FACILITY NUMBER: 013412413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2023
Section Cited
CCR
101212(c)

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101212(c)The licensee shall notify the Department in writing of his/her intent prior to making any structural changes that reduce the total amount of indoor or outdoor activity space. Such structural changes shall include, but not be limited to, room additions.This requirement is not met as evidenced by:
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Going forward, all structural changes incident reports shall notify the Community Care Licensing office within 24 hours of the occurrence, and a written report shall be submitted within seven days.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above. The licensee relocated the children without informing the CCLD, which poses a potential health and safety risk to the 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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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