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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408262
Report Date: 03/09/2022
Date Signed: 03/09/2022 01:24:24 PM

Document Has Been Signed on 03/09/2022 01:24 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:LEARNING EXPERIENCE, THEFACILITY NUMBER:
073408262
ADMINISTRATOR:ROBYN KINGFACILITY TYPE:
830
ADDRESS:4831 LONE TREE WAYTELEPHONE:
(925) 281-7640
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 13DATE:
03/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:RAJI PONNALURI TIME COMPLETED:
01:30 PM
NARRATIVE
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LICENSING PROGRAM ANALYST TASHA ALEXANDER MET WITH CENTER OWNER RAJI PONNALURI TO DISCUSS THE UNUSUAL INCIDENT REPORTED BY THE FACILITY ON 2/9/22. ACCORDING TO THE REPORT, IN THE MORNING, DURING CHECK IN, A CHILD WAS ABLE TO WALK OUT OF THE INFANT ROOM WITHOUT THE SUPERVISION OR KNOWLEDGE OF THE TEACHER OR AIDE. THE CHILD WAS WITHOUT ADULT SUPERVISION FOR APPROXIMATELY 10 TO 15 SECONDS.

ACCORDING TO TITLE 22 REGULATIONS, CHILDREN ARE TO BE VISUALLY SUPERVISED AT ALL TIMES.

PLEASE SEE THE ATTACHED 809-D FOR CITATION

THE LIC 9224 ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS HAS BEEN GIVEN AND EXPLAINED. A COPY OF THIS REPORT IS TO BE GIVEN TO EACH CHILD'S PARENT/GUARDIAN BY THE NEXT BUSINESS DAY AND A COPY OF THEIR SIGNED ACKNOWLEDGEMENT FORM IS TO BE INTO THEIR CHILD'S FILE. ANY NEWLY ENROLLED CHILD'S PARENT/GUARDIAN SHALL BE GIVEN A COPY OF THIS REPORT FOR UP TO 1 YEAR. THIS REPORT SHALL BE POSTED AT THE FACILITY FOR 30 DAYS.

AN EXIT INTERVIEW WAS CONDUCTED.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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 03/09/2022 01:24 PM - It Cannot Be Edited


Created By: Tasha Hackett-Alexander On 03/09/2022 at 10:57 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: LEARNING EXPERIENCE, THE
FACILITY NUMBER: 073408262

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2022
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.
(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
REQUIREMENT WAS NOT MET: WHEN A CHILD WAS ABLE TO WALK OUT OF THE INFANT ROOM DURING MORNING CHECK IN AND WAS WITHOUT ADULT VISUAL SUPERVISION FOR 10 TO 15 SECONDS
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PER OWNER ON 2/21/22 THE CENTER WAS CLOSED FOR THE DAY AND SHE HAD A STAFF MEETING AND HALF DAY OF TRAINING ON SAFETY MEASURES, INTAKE PROCEDURES, AND CHILD SUPERVISION.

DUE TO THE NATURE OF THIS INCIDENT, A NON-COMPLIANCE CONFERENCE WILL BE SCHEDULED WITH COMMUNITY CARE LICENSING
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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:Loretta Dyson
LICENSING EVALUATOR NAME:Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022


LIC809 (FAS) - (06/04)
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