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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 010205830
Report Date: 04/15/2024
Date Signed: 04/15/2024 01:21:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2024 and conducted by Evaluator Diana Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20240410100128

FACILITY NAME:AGNES MEMORIALFACILITY NUMBER:
010205830
ADMINISTRATOR:SANDRA PHELPSFACILITY TYPE:
850
ADDRESS:2372 INTERNATIONAL BLVDTELEPHONE:
(510) 533-1101
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY:24CENSUS: 13DATE:
04/15/2024
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Sandra PhelpsTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Building and Grounds-The facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA's) M. Mathur and D. Campos conducted an unannounced complaint inspection to investigate the above allegation. LPA's met with the Director Sandra Phelps. Present at the facility during the investigation were 4 fingerprint cleared staff, and 13 preschool children in care. A copy of the roster was obtained.
During the course of the investigation, interviews and observations were conducted.
It was alleged that facility is in disrepair. LPA's observed today some of the glass tiles on the classroom ceiling are either missing or broken which pose a potential hazard to children in care, large visible stains on classroom rugs, a broken handle and chipped paint on the slide section of the outdoor play structure. Cob webs also observed on the play structure. Feces observed under the wood chips, exposed tarp underneath wood chips posing a potential tripping hazard to children in care.
Based on the LPA's observations and interviews which were conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter Number (101416.5)), are being cited on the attached LIC 9099D.
Exit interview conducted and report reviewed with Director Sandra Phelps.
Notice of Site provided must remain posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
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 7
Control Number 02-CC-20240410100128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: AGNES MEMORIAL
FACILITY NUMBER: 010205830
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
101238(a)
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(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.This requirement was not met as evidenced by:
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Director shall submit a plan of action by 4/19/24 detailing how they will remain in compliance moving forward. Subsequently all items requiring repairs and corrections shall be completed by 5/15/24.
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LPA's observed missing glass tiles on the classroom ceiling, large stains on classroom rugs, broken handle, chipped paint and spider webs on the outdoor play structure and feces camouflaged by the large wood chips. Exposed tarp under the chips poses tripping hazard. This is a potential risk to the health and safety of children in care.
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LPA may return for an inspection to confirm corrections have been completed.
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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.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7