Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010213812
Report Date: 06/20/2017
Date Signed: 06/20/2017 10:00:42 AM

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:EMERYVILLE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
010213812
ADMINISTRATOR:PORTER, LOISFACILITY TYPE:
850
ADDRESS:1220 - 53RD STREETTELEPHONE:
(510) 596-4343
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY:66CENSUS: 43DATE:
06/20/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lois PorterTIME COMPLETED:
10:05 AM
NARRATIVE
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LPA Dayna Collier met with Center Director Lois Porter for a case management inspection as a result of receiving an unusual incident report. An incident occurred when two children had a disagreement over a toy, resulting in one child biting the other child on the cheek. The staff member supervising the area of play that these children were engaging in had walked off the yard to enter the classroom. When the staff member returned, one child was crying. None of the staff on the yard observed the incident. The children involved provided the details of the incident. First aid was applied and both children's parents were informed of the incident.

The attached type B deficiency is cited today and must be corrected by the due date. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and the signature on this form acknowledges receipt of these rights.

An exit interview was conducted and the report was discussed. A site visit notice was posted.
SUPERVISOR'S NAME: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: 510-725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2017
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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: EMERYVILLE CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 010213812
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2017
Section Cited
101229(a)(1)
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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).
TWO CHILDREN FOUGHT OVER A TOY RESULTING IN ONE CHILD BEING BITTEN BY THE OTHER CHILD WITHOUT STAFF'S KNOWLEDGE AND/OR OBSERVATION.
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POC: By 6/27/17, a written plan of action will be sent to Licensing detailing the steps staff will take to provide active visual supervision to all children in care at all times.
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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: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: 510-725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2017
LIC809 (FAS) - (06/04)
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