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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700598
Report Date: 03/01/2024
Date Signed: 03/01/2024 02:26:54 PM

Document Has Been Signed on 03/01/2024 02:26 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:PLAY PALS SPACE, LLCFACILITY NUMBER:
015700598
ADMINISTRATOR:PENDINGFACILITY TYPE:
850
ADDRESS:14207 E. 14TH STREETTELEPHONE:
(510) 612-5862
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 30TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
03/01/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Claire Ibrahim & Jacqueline Diaz De LeonTIME COMPLETED:
02:45 PM
NARRATIVE
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On 03/01/2024 at 8:30am, Licensing Program Manager (LPM) Chandra Charles and Licensing Program Analysts (LPAs) Christina Uribe & Lorraine Dacanay-Breaux conducted an unannounced visit for the purpose of a Case Management inspection. LPAs met with licensee, Claire Ibrahim, & site director, Jacqueline Diaz De Leon. Also present at the time of the inspection is 3 staff members and 8 children.

Personnel and children's records were reviewed by LPAs and LPM. During this record review, several deficiencies were found resulting in the issuance of 8 Type B Violations. The violations are:
  • Type B Violation: One staff member does not have proof of immunization against Measles (MMR) and two staff members do not have proof of immunization against Influenza.
  • Type B Violation: One staff member does not have a Health Screening Report (LIC 503) or proof of a TB clearance.
  • Type B Violation: The facility does not have a qualified director employed.
  • Type B Violation: Three children's files do not have a Physician's Report (LIC 701).
  • Type B Violation: One child's files does not have immunization record. 4 children's records need an updated immunization record.
  • Type B Violation: One child's file does not have the Identification & Emergency (LIC 700) form.
  • Type B Violation: One child's prescription medication does not have an original package nor prescription label.
  • Type B Violation: Facility has incomplete children's files.

Please see attached deficiency pages (LIC 809D's) for additional information on violations issued today and corresponding Plan of Correction due dates.

Page 1 of 2 ***Continued on LIC 809C***
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2024
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: PLAY PALS SPACE, LLC
FACILITY NUMBER: 015700598
VISIT DATE: 03/01/2024
NARRATIVE
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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. Exit interview was conducted and report was reviewed with licensee, Claire Ibrahim.



























Page 2 of 2 ***End of Report***
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/01/2024 02:26 PM - It Cannot Be Edited


Created By: Christina Uribe On 03/01/2024 at 12:49 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: PLAY PALS SPACE, LLC
FACILITY NUMBER: 015700598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
101216(g)(1)

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101216(g)(1) Personnel Requirements - Good physical health of all personnel 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.
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Staff member will schedule an appointment with their physician for a health assessment and receive a tuberculosis test. Licensee will email the completed Health Screening Report (LIC 503) and proof of TB clearance to LPA Dacanay-Breaux no later than the due date of 03/29/24.
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This requirement was not met as evidenced by:

One staff member does not haved a Health Screening Report (LIC 503) nor proof of a TB clearance.
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Type B
03/29/2024
Section Cited
CCR101220.1(g)

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101220.1(g) Immunizations - The licensee shall document each child's immunization records and shall maintain such documentation in the center for as long as the child is enrolled.
This requirement was not met as evidenced by:
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Licensee will obtain updated immunization records for the five children and email these records to LPA Dacanay-Breaux no later than the due date of 03/29/2024.
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One child's file does not have any record of immunizations. 4 other children's immunization records need to be updated as it only provides proof of having received one of the three required doses of Hepatitis B vaccine.
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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: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/01/2024 02:26 PM - It Cannot Be Edited


Created By: Christina Uribe On 03/01/2024 at 01:02 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: PLAY PALS SPACE, LLC
FACILITY NUMBER: 015700598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
101215.1(b)

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101215.1(b) Child Care Center Director Qualifications and Duties - All child care centers shall have a director.

This requirement was not met as evidenced by:
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Licensee will submit a completed director packet or submit an exception request via email to LPA Dacanay-Breaux no later than the due date of 03/29/2024.
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The facility does not have a qualified director. The individual assigned as the director needs to meet several requirements to qualify as a director.
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Type B
03/29/2024
Section Cited
HSC1596.7995(a)(1)

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1596.7995(a)(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a child care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccine between 08/01-12/01 of each year.
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Staff members will obtain record of immunization against measles (MMR) and/or influenza. Licensee will email these documents to LPA Dacanay-Breaux no later than the due date of 03/29/2024
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This requirement was not met as evidenced by:

One staff member does not have record of immunization against Measles (MMR). Two staff members do not have record for influenza.
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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: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/01/2024 02:26 PM - It Cannot Be Edited


Created By: Christina Uribe On 03/01/2024 at 01:14 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: PLAY PALS SPACE, LLC
FACILITY NUMBER: 015700598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
101221(a)

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101221(a) Child's Records - A separate, complete, and current record of each child shall be maintained at the child care center.

This requirement was not met as evidenced by:
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Licensee will ensure that all children's files are complete and up to date. Licensee was provided with a list of which chidren's files needed which forms to be completed. Licensee will email a copy of each of these documents from the list to LPA Dacanay-Breaux no later than the due date of 03/29/24.
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Several children's files had incomplete documents and are need of being completed by the children's authorized representatives.
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Type B
03/29/2024
Section Cited
CCR101221(b)(5)

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101221(b)(5) Child's Records - (b) Each record shall contain information including, (5) Name, address, and telephone number of the child's authorized representative and of relatives or others who can assume responsibility for the child is the authorized representative cannot be reached when
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Licensee will ensure that this child's parent completes and signs the Identification & Emergency (LIC 700) form. Licensee will email a copy of this form to LPA Dacanay-Breaux no later than the due date of 03/29/24.
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necessary.

This requirement was not met as evidenced by:

One child does not have a Identification and Emergency (LIC 700) form in their file.
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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: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/01/2024 02:26 PM - It Cannot Be Edited


Created By: Christina Uribe On 03/01/2024 at 01:22 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: PLAY PALS SPACE, LLC
FACILITY NUMBER: 015700598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
101221(b)(8)

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101221(b)(8) Child's Records - (b) Each record shall contain information including, (8) Medical assessments.

This requirment was not met as evidenced by:
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Licensee will ensure that the authorized representative of these children schedule medical assessment for their child and obtain a Physician's Report (LIC 701) completed by the physician. Licensee will email these completed forms to LPA Dacanay-Breaux no later than the due date of 03/29/24.
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Three children's files do not have a completed Physician's Report (LIC 701) form.
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Type B
03/29/2024
Section Cited
CCR101226(e)(1)(B)

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101226(e)(1)(B) Health Related Services - (e)(1) All prescription and non-prescription medications shall be centrally stored in accordance with (B) Each container shall have an unaltered label.
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Licensee will ensure that the child's authorized representative provides the original package and the prescription label for the prescribed medication. Licensee will email a photo of the prescription medication box and label and email it to LPA Dacanay-Breuax no later than the due date of 03/29/24.
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This requirement was not met as evidenced by:

One child's prescription medication did not include the original packaging nor the prescription label.
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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: 03/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2024


LIC809 (FAS) - (06/04)
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