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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434412177
Report Date: 09/13/2023
Date Signed: 09/13/2023 01:00:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2023 and conducted by Evaluator Jyoti Saini
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20230907100842
FACILITY NAME:CLUB J AT THE OSHMAN FAMILY JCCFACILITY NUMBER:
434412177
ADMINISTRATOR:MALLARE, CYRUSFACILITY TYPE:
840
ADDRESS:3921 FABIAN WAYTELEPHONE:
(650) 223-8625
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:192CENSUS: 0DATE:
09/13/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Director, Cyrus Mallare- DiethornTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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-Staff did not provide adequate supervision to a daycare child
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jyoti Saini met with Director Cyrus Mallare- Diethorn for a 10-day complaint visit. There are no children present during the inspection today.
Based on interviews and record reviews, which include a self-reported incident that occurred on 09/05/2023, where the facility acknowledged that the child was left unattended in the school van from 2:45 pm to 4:00 pm, which concludes that staff did not provide adequate supervision to children in care. The preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, {Title 22, Division & Chapter Number 101229(a)(1)} is being cited on the attached LIC 9099D.
LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.
see next page...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 52-CC-20230907100842
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CLUB J AT THE OSHMAN FAMILY JCC
FACILITY NUMBER: 434412177
VISIT DATE: 09/13/2023
NARRATIVE
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An immediate civil penalty of 500$ is assessed today.

An exit interview was conducted with director, Cyrus Mallare- Diethorn.

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

The Facility's appeal rights were reviewed and given to the director, Cyrus Mallare- Diethorn.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 52-CC-20230907100842
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: CLUB J AT THE OSHMAN FAMILY JCC
FACILITY NUMBER: 434412177
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2023
Section Cited
CCR
101229(a)(1)
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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
This requirement was not met, as evidenced by:
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The director shall submit a written plan to the community care licensing division (CCLD) on how the facility and staff will always ensure complete supervision of all children in care. The director shall also conduct in-house training on care and supervision, provide a copy to all staff members, and have them sign the plan.

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Based on the interview and record review, C1 was left unattended in school van which poses an immediate health and safety risk to children in care
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An immediate civil penalty of $500 is assessed today.
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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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2023 and conducted by Evaluator Jyoti Saini
COMPLAINT CONTROL NUMBER: 52-CC-20230907100842

FACILITY NAME:CLUB J AT THE OSHMAN FAMILY JCCFACILITY NUMBER:
434412177
ADMINISTRATOR:MALLARE, CYRUSFACILITY TYPE:
840
ADDRESS:3921 FABIAN WAYTELEPHONE:
(650) 223-8625
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:192CENSUS: 0DATE:
09/13/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Director, Cyrus Mallare- DiethornTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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2
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9
-Staff locked a daycare child in the facility's vehicle.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jyoti Saini met with Director Cyrus Mallare- Diethorn for a 10-day complaint visit. There are no children present during the inspection today.
Based on interviews and record reviews, including a self-reported incident that occurred on 09/05/2023, acknowledging that the facility forgot to escort the child out of the school van after being transported from primary school to an after-school program. The child was left locked and unattended for one hour and 15 minutes in the facility’s vehicle. The preponderance of evidence standard has been met; therefore, the allegation is found to be SUBSTANTIATED.California Code of Regulations, {Title 22, Division & Chapter Number 101223(a)(6)} is being cited on the attached LIC 9099D.
LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.
An exit interview was conducted with director, Cyrus Mallare- Diethorn.
A notice of site visit was given and must remain posted for a period of 30 days.
The Facility's appeal rights were reviewed and given to the director, Cyrus Mallare- Diethorn.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 52-CC-20230907100842
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: CLUB J AT THE OSHMAN FAMILY JCC
FACILITY NUMBER: 434412177
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2023
Section Cited
CCR
101223(a)(6)
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Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:(6) Not to be locked in any room, building or center premises by day or night.
This requirement was not met, as evidenced by:
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The director shall submit a written plan to the community care licensing division (CCLD) on how the facility will prevent similar occurrences in future. The director shall also conduct in-house training on personal rights.
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Based on the interview and record review, C1 was left unattended and locked for one hour and 15 minutes in the school van while being transported from primary school to an after-school program, which poses an immediate 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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Jyoti SainiTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5