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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010214002
Report Date: 04/15/2022
Date Signed: 04/15/2022 11:56:20 AM


Document Has Been Signed on 04/15/2022 11:56 AM - 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 STE 1102
OAKLAND, CA 94612



FACILITY NAME:ADVENTURE TIME - PARKMONTFACILITY NUMBER:
010214002
ADMINISTRATOR:SANDERS, VALINAFACILITY TYPE:
840
ADDRESS:2601 PARKSIDE DRIVETELEPHONE:
(510) 713-2011
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:115CENSUS: 10DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Heather PitruzelliTIME COMPLETED:
12:15 PM
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On April 15, 2022 at approximately 8:15am, LPA Haderer arrived unannounced for an annual inspection for compliance to Health and Safety. The new CARE tool was used for the inspection. Present for the inspection was the site director Heather Pitruzello (substituting for Valina Sanders who was on vacation), Program Supervisor Jayjay Nagayo, two teachers and 11 children in care (all school age). The center currently operates from 7:00 to 6:00PM, the center is in ratio today.

The child care center operates in a large portable room on the campus of Parkmont Elementary School. The children use the school playground, all equipment is in safe condition and free from sharp, loose, or pointed parts and the areas around or under high climbing equipment has appropriate cushioned material that absorbs a fall. Access to drinking water is available and teachers are always present.



All documents required to be posted were appropriately posted on the walls: License; Emergency Disaster Plan; Earthquake Preparedness checklist; Notification of Parents Rights; Personal rights; Child seatbelt laws; menus; daily activity schedules.

The facility has 2 fully charged 3A40BC fire extinguishers, one mounted next to each door in the classroom. The last annual inspection was done 7-15-2021. Fremont Alarm conducts fire inspections, the last one was completed 11/30/2021, all smoke detects properly functioning. The carbon monoxide detector was tested and functioning. Heating and ventilation in the classroom is acceptable. Disaster drills are conducted at least once each month, the last drill was conducted 2-14-2021.

The facility is clean and well organized with ample age appropriate furnishings and equipment. Surfaces including floors and counter tops are clean and toxic free. Hazardous items/toxins are kept in a locked cabinet in the staff snack prep area out of the access of children. No bodies of water are accessible to children in care.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
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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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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: ADVENTURE TIME - PARKMONT
FACILITY NUMBER: 010214002
VISIT DATE: 04/15/2022
NARRATIVE
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The facility does not provide lunch, snacks are provided. During the inspection, some expired tortilla chips were found in the cupboard and expired cream cheese in the refrigerator. See LIC809D.

Children use the school bathrooms on campus, children are escorted in groups when they need to use the facilities. The staff has a separate adult bathroom located on campus.

The sign in/out sheets were reviewed and are accurate. Classrooms have trash cans with tight fitting cover for ren disposal of solid waste. There are 4 children that require incidental medication (EpiPen’s and antihistamines), all medications were not expired, and signed parent authorization forms were in with the medications.



Children's records were reviewed: LPA requested and reviewed facility roster. All files selected were complete and up to date. Staff files were reviewed. Opening and closing staff have current CPR and first aid training. One staff file was missing any proof of measles vaccine (MMR) and another staff member’s file was missing proof of TB and there was no Health History Report. See LIC809D.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Site Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: ADVENTURE TIME - PARKMONT
FACILITY NUMBER: 010214002
VISIT DATE: 04/15/2022
NARRATIVE
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There were three deficiencies cited today, please see LIC809D for details.

A notice of site visit was given and must remain posted for 30 days.



Exit interview conducted and report was reviewed with the Program Supervisor Jayjay Nagayo.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/15/2022 11:56 AM - 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 STE 1102
OAKLAND, CA 94612


FACILITY NAME: ADVENTURE TIME - PARKMONT
FACILITY NUMBER: 010214002

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one employee file was missing any proof of measles (MMR) vaccination or blood test showing immunity which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Program Supervisor will ensure employee provides proof of vaccination or a blood test to prove immunity to Measles.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health 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 or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that one Employee file was missing the Health History report and proof of TB clearance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Program Supervisor will ensure that employee provides a Health History Report LIC503 and proof test showing negative to TB.

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 CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 04/15/2022 11:56 AM - 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 STE 1102
OAKLAND, CA 94612


FACILITY NAME: ADVENTURE TIME - PARKMONT
FACILITY NUMBER: 010214002

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101227(a)(1)
Food Service
(a) In child care centers providing meals to children, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the children. Each meal shall include, at a minimum, the amount of food components as specified by Title 7, Code of Federal Regulations, Part 226.20, (Revised January 1, 1990) Requirements for Meals, for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that during the inspection, some expired tortilla chips were found in the cupboard and expired cream cheese in the refrigerator which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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Program Supervisor immediately pulled the expired foods and disposed of them in the trash.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5