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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408882
Report Date: 04/21/2022
Date Signed: 04/21/2022 02:42:24 PM

Document Has Been Signed on 04/21/2022 02:42 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:ADVENTURE KINDERLAND AKADEMYFACILITY NUMBER:
073408882
ADMINISTRATOR:SCOTT, THOMASFACILITY TYPE:
850
ADDRESS:12411 SAN PABLO AVENUETELEPHONE:
(510) 680-5242
CITY:RICHMONDSTATE: CAZIP CODE:
94805
CAPACITY: 35TOTAL ENROLLED CHILDREN: 35CENSUS: 3DATE:
04/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:THOMAS SCOTTTIME COMPLETED:
03:01 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Melissa Domantay and Melissa Guirit arrived to the facility unannounced to conduct a Case Management inspection and met with licensee Thomas Scott. Present during today's visit were 3 preschool children and licensees daughter.


LPAs performed a health & safety check. See 809-D for the TYPE B deficiencies that is being cited on today's visit.

An exit interview was conducted. The licensee THOMAS SCOTT, was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Melissa Domantay
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 04/21/2022 02:42 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/21/2022 at 01:54 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ADVENTURE KINDERLAND AKADEMY
FACILITY NUMBER: 073408882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited
CCR
101215.1(d)

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This requirement was not met as evidenced by no director being present at facility. This poses a potential health and safety risk to children in care.
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Licensee will provide a completed director qualifications packet to LPA Domantay or LPA Guirit and have director present at center while child care is being provided.
Type B
04/29/2022
Section Cited
CCR
101237(a)

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This requirement was not met as evidenced by licensed classroom was altered. This poses a potential health and safety risk to children in care.
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Licensee shall request to remove back classroom if it will not be used for child care purposes or ensure classroom is set up to be utilized for children in care.
Type B
05/05/2022
Section Cited
CCR101238.2(d)(1)(2)

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This requirement was not met as evidenced by boat and car is parked in the outdoor activity space. This poses a potential health and safety risk to children in care.
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Licensee shall remove boat and car from outdoor activity space.
Type B
04/28/2022
Section Cited
CCR
101216.1(b)(1)(A)(2)

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This requirement was not met as evidenced by no qualified teacher on site at facility. This poses a potential health and safety risk to children in care.
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Licensee must ensure that a qualified teacher is present at facility while children are in care.
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/21/2022 02:42 PM - It Cannot Be Edited


Created By: Melissa Domantay On 04/21/2022 at 02:21 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ADVENTURE KINDERLAND AKADEMY
FACILITY NUMBER: 073408882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2022
Section Cited
CCR
101238(a)

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This requirement was not met as evidenced by center is in disarray. This poses a potential health and safety risk to children in care.
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Licensee shall ensure center is organized to ensure the health and safety of children, employees, and vistors.

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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Melissa Domantay
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022


LIC809 (FAS) - (06/04)
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