015700540-10-15-2024-52-CC-BPLY-DA3TTZ-20241015150134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015700540
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:01:53 PM

Document Has Been Signed on 10/15/2024 03:01 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 EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	ADVENTURE MONTESSORI ACADEMY		FACILITY NUMBER:	015700540
ADMINISTRATOR/ DIRECTOR:	BRODOWSKI, ELIZABETH		FACILITY TYPE:	850
ADDRESS:	4101 PLEIADES PLACE		TELEPHONE:	(408) 464-3131
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 22	CENSUS: 22	DATE:	10/15/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:00 PM
MET WITH:	Gunasundari Vijayan- Director		TIME VISIT/ INSPECTION COMPLETED:	03:15 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	On 10/15/24 at approximately 12:00pm, Licensing Program Analyst (LPA) Briana Plumboy met with Director Gunasundari Vijayan, and Assistant Director Elizabeth Brodowski for an unannounced annual random inspection. The center and playground were toured to conduct a Health and Safety inspection. There were 22 preschool age children present during the visit, as well as 3 fingerprint clear and associated teachers (N.Kaur, J.Narayanani, and L.Vasquez). The center currently operates from 7:30am until 5:30pm in 5 classrooms. There is storage for children's belongings. There is furniture, toys and activities present during today's inspection. The heating and lighting is adequate. There is drinking water readily available to children both indoor and outdoor during today's inspection. Each child in care brings a water bottle to the center each day with them, and when the child plays outside, the water bottle is brought outside with them. There are cups readily available for children's use in the case they do not have a water bottle. There are 3 combined bathrooms for boys and girls. There is running water, soap, and paper towels available for children to wash and dry their hands during today's inspection. There is a separate bathroom for staff. There are no bodies of water, or free standing water, accessible to children during today's inspection of the facility. Per director, there are no firearms on the premises of the child care center. The snacks and lunches are provided by the families for their child in care. The center has emergency snacks available in the case a child does not bring theirs. There are no cleaning supplies stored with snacks. The kitchen is inaccessible by half doors. There are ample mats and sheets available for children's use, and they are stored properly. The playground has age appropriate equipment. All required documents are posted for public review. The center is in compliance with the sign in and out procedure. Disaster drills are being conducted at least once every 6 months, and the log indicates the last disaster drill was conducted on 8/7/24. The center is equipped with a first aid kit, working telephone, carbon monoxide detector, pull down fire alarm and two 2A10BC fire extinguishers. A review of 5 children's files and 3 staff files was completed. All staff members have current CPR/First Aid certificate. All staff members are in compliance with the mandated reporter training. continued on 809C and 809Ds

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

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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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: ADVENTURE MONTESSORI ACADEMY	FACILITY NUMBER: 015700540
	VISIT DATE: 10/15/2024

NARRATIVE

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All required forms are posted. Lic. 500 and facility roster was reviewed. This facility does provide incidental medical services (IMS) to the children. LPA reminded director to have all prescribed and non-prescribed medications to have original containers with unaltered labels.

Incidental Medical Services (IMS) policy was discussed. This facility provides IMS to children in care. The facility is following and have developed IMS plan on file. When any changes to the IMS plan is made, an updated Plan for Providing IMS must be submitted to the Department. 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.”

Director was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed facility. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Director was reminded that California Law requires licensed Child Care Centers to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail.

LPA informed the Facility Representative that all forms can be downloaded at www.ccld.ca.gov and encouraged the Facility Representative to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

The Director is reminded any structural changes to the center or additions to the child care facility must be reported to Community Care Licensing. Director was reminded of Departments inspection authority, with our without any notice.

Director was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates.

See 809-D for deficiencies cited today. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/15/2024 03:01 PM - It Cannot Be Edited

Created By: Briana Plumboy On 10/15/2024 at 02:27 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: ADVENTURE MONTESSORI ACADEMY	FACILITY NUMBER: 015700540
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238(a)

Buildings and Grounds

(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to their being a broken sink, broken toilet, the wall heater is not inaccessible, there is a house structure outside in the play yard where the wood has rotted, and the floor heaters are not covered which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2024
	Plan of Correction
1 2 3 4	On or before 10/25/24, Director will submit plans/ work orders as to how the items meaned above will be fixed/ removed/ made inaccessible to children in care.

Type B

Section Cited

CCR

101221(b)(8)(C)

Child's Records

(C) A signed consent form for emergency medical treatment unless the child's authorized representative has signed the statement specified in Section 101220(f). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review of C3's file, the licensee did not comply with the section cited above by not obtaining a signed Lic.627 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	On or before 10/18/24, Director will submit a copy of the signed Lic.627 to LPA Plumboy for C3.

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 Norona

LICENSING EVALUATOR NAME:

Briana Plumboy

LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC809 (FAS) - (06/04)

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