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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700580
Report Date: 08/15/2025
Date Signed: 08/15/2025 01:38:46 PM

Document Has Been Signed on 08/15/2025 01:38 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:HUSD - BURBANK PRESCHOOLFACILITY NUMBER:
015700580
ADMINISTRATOR/
DIRECTOR:		RUBIO, ANN KRISTINNEFACILITY TYPE:
850
ADDRESS:222 BURBANK STREETTELEPHONE:
(510) 723-3805
CITY:HAYWARDSTATE: CAZIP CODE:
94541
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 11DATE:
08/15/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Jackie Amo-MenshTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On August 15, 2025 at 11:30 AM., Licensing Program Analyst (LPA) Elimika Woods conducted an unannounced Annual Random Inspection and met with the director, Jackie Amo-Mensh. LPA disclosed the purpose of the inspection and the facility was toured for a health and safety inspection. There were 11 preschool age children present during this inspection and two (2) additional staff members. The facility is located on the campus of Burbank Elementary School in Room 7. The hours of operation are 8:10 AM to 11:10 AM for morning session, and 11:40 AM to 2:40 PM for afternoon session.. .

All individuals subject to criminal record review have a clearance or exemption and have been associated to the facility. LPA conducted a census of the children and the census matches the 11 signatures signed in on the sign in sheet. LPA reviewed four children in care files around 12:00 PM, and all the files contained Medical Consent forms, Personal Rights, and Identification & Emergency Information. This center has two waivers from the licensing department, one is to share the second bathroom with the elementary school and the other is the share use of the outdoor activity space which was granted by the Licensing Department in 2022.

The center has wired smoke & carbon monoxide detectors. Smoke detector is wired to notify the fire department when triggered. Per Director, smoke detector is fully functional and serviced regularly.


This center has a working telephone, first aid equipment, and a fully charged 3A40BC fire extinguisher, which meets standards established by the State Fire Marshal hanging on the wall next to the entrance door.

Staff files are maintained and stored in the Hayward School Districts Human Resource Office and all licensing requirements for personnel are met as a condition of employment with the school district. At least one opening/ closing staff member has a current CPR & First Aid Certificate. Disaster drills are being conducted at least once every 6 months in conjunction with the Hayward Unified School District schedule.

See 809-C.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: HUSD - BURBANK PRESCHOOL
FACILITY NUMBER: 015700580
VISIT DATE: 08/15/2025
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The one (1) classroom was inspected around 11:40 AM and the center was in ratio. The center uses low shelves to divide spaces so children can choose and return items independently. The classrooms is set up for staff to see all of the children in the different areas. The classroom has soft flooring such as rugs, and carpets for play areas, and the floors are clean. The furniture was the correct size for preschool age children and the play equipment is age appropriate.

The children's bathroom is located inside the classroom and the bathroom has one sink, and one toilet for children to use. LPA verified that the toilet was working properly by flushing it, to make sure it was functioning properly. The center has plenty of soap, bath tissue, and paper towels available to children in care. LPA was told by the director that the staff's bathroom is located in the schools main building and that it was separate from the children’s bathroom.

This facility provides lunch for children in care and they have weekly menus posted on the parent board at the facility. The center also sends the food menu out through class Dojo. LPA observed an area where they have a mini refrigerator this area is clean and free of evidence of rodents. LPA reminded the facility representative that all persons engaged in food preparation and service shall observe personal hygiene and food service sanitation practices to protect food from contamination. All storage containers for solid waste have tight fitting covers that are in good repair.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, a 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: https://www.ada.gov/resources/child-care-centers/



LPA Observation during Inspection- at 12:00 PM, The staff did roll call with the children while they were finishing with their lunch. During circle time, the staff effectively engaged children through story telling, and discussions. The staff maintained a warm and welcoming tone, and encouraged participation by asking open-ended questions. Materials were prepared in advance, and the flow was smooth and without delays.

LPA checked the playground area around 1:00 PM and found it free from defects and dangerous conditions during todays inspection. The playground has an awning and trees that provides shade to children while at play. There's a play structure with a slide that's anchored into the ground with cushioning underneath to absorb children's falls. The play equipment is age appropriate for preschool age children and in good repair.

See 809-C.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
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: HUSD - BURBANK PRESCHOOL
FACILITY NUMBER: 015700580
VISIT DATE: 08/15/2025
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California Law requires Child Care Centers 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 by phone, fax, or electronic mail. The director 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.

Lead Testing – Child Care Centers (CCC) CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES: 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 21-21.1CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

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.

The 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.

The 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.

There are no deficiencies cited today. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the director, Jackie Amo-Mensh.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC809 (FAS) - (06/04)
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