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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700550
Report Date: 01/19/2024
Date Signed: 01/19/2024 01:42:24 PM

Document Has Been Signed on 01/19/2024 01:42 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:PILGRIM LEARNING ACADEMYFACILITY NUMBER:
015700550
ADMINISTRATOR:VERVILLE, SHELLYFACILITY TYPE:
850
ADDRESS:20613 STANTON AVENUETELEPHONE:
(510) 581-1580
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 54TOTAL ENROLLED CHILDREN: 33CENSUS: 16DATE:
01/19/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kristy TruscottTIME COMPLETED:
02:00 PM
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On 01/19/2024 at 8:30am, Licensing Program Analyst (LPA) Christina Uribe conducted an Unannounced Annual Required Inspection. LPA met with facility representative Kristy Truscott, also present at the time of the inspection were 3 staff & 16 children. The site director, Shelly Verville, arrived and took over the inspection process with LPA Uribe at 11:45am. The facility is within ratio & capacity compliance today. LPA provided facility representative the Entrance Checklist (LIC 125). The facility was toured to conduct a Health and Safety inspection. The facility currently operates 7:00am-6:00pm, Monday-Friday in two classrooms.

Classrooms: All classrooms were inspected for age-appropriate furnishings, equipment, & adequate storage for children’s belongings. LPA observed the cleanliness of floors & surfaces, the presence of a fully functional carbon monoxide detector, smoke detector/fire alarms, and a fully charged 3A40BC fire extinguisher that is accessible throughout the facility. The center is equipped with a fully stocked first-aid kit and available in the classrooms.

Food Service Areas: All center provided food items are properly labeled & stored separately from cleaning supplies. Food prep area is clean, adequately equipped, & free from hazardous materials. Snack menu is posted one week in advance, available for review, & dated. Solid waste bins are equipped with tight fitting lid.

Bathrooms: Facility has separate staff and child designated bathrooms. Toilets and faucets are in safe and sanitary operating condition. The children are able to reach the sinks, toilets, and supplies.

Outdoor Play Area: The playground outside is fenced and all equipment and surfaces are free from hazards. There are no bodies of water, or free-standing water accessible to children. There are age appropriate outdoor toys and materials for the children.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PILGRIM LEARNING ACADEMY
FACILITY NUMBER: 015700550
VISIT DATE: 01/19/2024
NARRATIVE
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Records: All individuals subject to criminal record review have a clearance and have been associated to the facility. LPA reviewed 5 children’s files and 8 staff files. LPA reviewed the facility roster & personnel report. LPA reviewed transcripts and signed Evaluation of Teacher Qualification (LIC 9095) forms for 2 staff members. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Mandated Reporter certificates were reviewed. Director was reminded of their responsibility to renew CPR/First Aid and Mandated Reporter certificates every two years. The center is in compliance with sign in and out procedure. Emergency Drills are recorded and performed at least every six months. Per facility representative, there are no firearms on the premises. All required documents are posted in a publicly accessible area.

CCLD Inspection Process: To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Criminal Record Clearance: Director 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.

Incidental Medical Services (IMS): This facility does provide Incidental Medical Services (IMS). LPA inspected storage of medications and equipment/supplies, and reviewed children’s, personnel, and administrative records. All children’s medications are securely stored, accompanied by their original packaging for compliance. 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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at http://www.ada.gov/resources/child-care-centers/.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
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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: PILGRIM LEARNING ACADEMY
FACILITY NUMBER: 015700550
VISIT DATE: 01/19/2024
NARRATIVE
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MyChildCarePlan.org: Director 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.

Unusual Incident/Student Injury Report: Effective August 1, 2003 California Law requires Child Care Licensees 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 to the regional office by phone and the written report, LIC 624, within 7 business days.

List of deficiencies and advisory notes issued today:

  • Type B Violation: Some staff members need to obtain a Mandated Reporter certificate for Child Care Providers.
  • Type B Violation: Some staff members need to obtain a Health Screening Report (LIC 503) and proof of TB clearance.
  • Type B Violation: Some staff members need to obtain proof of immunization against Measles (MMR) and/or Pertussis (Tdap).
  • Advisory Note (TV): Some children's records are incomplete and need to be corrected.
  • Advisory Note (TV): One child's prescription chamber for the administration of inhaled medication needs to be discarded according to the prescription label.
  • Advisory Note (TV): Some staff members do not have a signed Employee Rights (LIC 9052) form.
  • Advisory Note (TA): Emergency drills are performed at least every 6 months but need to be properly recorded on an Emergency Drill Log.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal rights were given and reviewed. Exit interview conducted and report was reviewed with the director, Shelly Verville.

Page 3 of 3 ***End of Report***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 01/19/2024 01:42 PM - It Cannot Be Edited


Created By: Christina Uribe On 01/19/2024 at 12:46 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: PILGRIM LEARNING ACADEMY
FACILITY NUMBER: 015700550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as some staff members do not have a Mandated Reporter certificate for Child Care Providers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Director will have all staff members obtain a Mandated Reporter certificate for Child Care Providers from www.mandatedreporterca.com no later than the due date of 02/19/24. LPA Uribe will return to the facility after the due date of 02/19/2024 to verify this has been completed.
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 as some staff members do not have proof of immunization against Measles (MMR) and/or Pertussis (Tdap) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Director will ensure that all staff members obtain proof of immunization against Measles (MMR) and Pertussis (Tdap) no later than the due date of 02/19/24. LPA Uribe will return to the facility after the due date of 02/19/2024 to verify this has been completed.
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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/19/2024 01:42 PM - It Cannot Be Edited


Created By: Christina Uribe On 01/19/2024 at 12:46 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: PILGRIM LEARNING ACADEMY
FACILITY NUMBER: 015700550

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/19/2024

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 as some staff members do not have a Health Screeing Report (LIC 503) form and/or proof of TB clearance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2024
Plan of Correction
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Director will ensure that all staff members have obtained a Health Screening Report (LIC 503) and proof of TB clearance no later than the due date of 02/19/24. LPA Uribe will return to the facility after the due date of 02/19/2024 to verify this has been completed.
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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2024


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