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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700596
Report Date: 10/11/2023
Date Signed: 10/11/2023 12:28:09 PM

Document Has Been Signed on 10/11/2023 12:28 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:LITTLE APPLE ACADEMYFACILITY NUMBER:
015700596
ADMINISTRATOR:LEI, TONGXINFACILITY TYPE:
830
ADDRESS:2000 EAST 14TH STREETTELEPHONE:
(415) 623-0837
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 26TOTAL ENROLLED CHILDREN: 26CENSUS: 6DATE:
10/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Wenyan ShiTIME COMPLETED:
12:45 PM
NARRATIVE
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On October 11, 2023, Licensing Program Analyst (LPA) Simerjit Kaur conducted an unannounced Case management inspection and to deliver the findings of the complaint (received on September 14, 2023). The complaint investigation was conducted by investigator Megan Mullen. LPA Kaur met with Assistant Director Wenyan Shi. Present during the inspection, there were 6 infant children and 2 staff.

During the course of investigation, Investigator Mullen determined the facility failed to timely report unusual incident to Community Care Licensing, failed to timely seek medical care for a child, Assistant director was not associated to facility. Present during the inspection today, there were 6 infant age children with 4 preschool age children in one room.

The attached type B and type A violations are cited today with civil penalty. Upon receipt, Assistant Director Wenyan Shi shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgment form of proof of receiving this report (LIC9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.

LPA Kaur scheduled informal conference with Director and Assistant Director. LPA read the report with Wenyan Shi and Director Tongxin Lei. The LPA provided copy of appeal rights. A Notice of Site visit was posted at the time of inspection and must remain posted for 30 days.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Simerjit Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
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 10/11/2023 12:28 PM - It Cannot Be Edited


Created By: Simerjit Kaur On 10/11/2023 at 10:06 AM
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: LITTLE APPLE ACADEMY
FACILITY NUMBER: 015700596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/12/2023
Section Cited
CCR
101170(e)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or
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LPA Kaur was able to associated staff by transferring her in Guardian.
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Assistant director is not associated to the facility.
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TODAY AN IMMEDIATE CIVIL PENALTY OF $500 IS ASSESSED, due to employee not associated to facility. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrented. See LIC421BG.

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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:Jason Jang
LICENSING EVALUATOR NAME:Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


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Document Has Been Signed on 10/11/2023 12:28 PM - It Cannot Be Edited


Created By: Simerjit Kaur On 10/11/2023 at 10:34 AM
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: LITTLE APPLE ACADEMY
FACILITY NUMBER: 015700596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2023
Section Cited
HSC
101161(a)

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101161(a) The licensee shall not exceed the conditions, limitations and capacity specified in the license.
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Effective immediately, licensee/assistant director shall develop a plan to ensure infant age children are not to commingle with preschool age children. Licensee shall submit a copy of the plan to CCL by 10/18/2023.
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This requirement was not met based upon observation and record review. LPA observed 4 preschool age children with 6 infant age children in one room. This poses a potential safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation.

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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:Jason Jang
LICENSING EVALUATOR NAME:Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/11/2023 12:28 PM - It Cannot Be Edited


Created By: Simerjit Kaur On 10/11/2023 at 10:47 AM
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: LITTLE APPLE ACADEMY
FACILITY NUMBER: 015700596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2023
Section Cited
CCR
101212(d)(1)

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Reporting Requirements -Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be ...seven days following the occurrence of such event.
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1)Facility Director and staff will watch the CCL training video for “Child Care Reporting Requirements” on ccld.ca.gov, 2) Director shall submit a statement of the responsibility of following the reporting requirements regulation.
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This requirement was not met as evidenced by: Facility did not timely contact CCL to report incident which occurred on 9/5/2023. This poses a potential safety & health risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type B
10/18/2023
Section Cited
CCR101226(c)

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The licensee shall obtain emergency medical treatment without specific instructions from the child's authorized representative if the authorized representative cannot be reached immediately, or if the nature of the child's illness or injury is such that there should

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Facility Director shall submit a plan of action detailing steps the all staff will take to handle medical emergencies.
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be no delay in getting medical treatment for the child. Based on interviews conducted by investigator Mullen, the licensee did not comply with the section cited above, the facility failed to seek timely medical care for a child, which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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:Jason Jang
LICENSING EVALUATOR NAME:Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


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