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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: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.

SUPERVISOR'S NAME: Mayla MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Melissa DomantayTELEPHONE: 510-725-7021
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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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

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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.
Type B
04/29/2022
Section Cited

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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.
Type B
05/05/2022
Section Cited

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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.
Type B
04/28/2022
Section Cited

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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.
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 MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Melissa DomantayTELEPHONE: 510-725-7021
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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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

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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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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 MendozaTELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Melissa DomantayTELEPHONE: 510-725-7021
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: 3 of 3