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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010206139
Report Date: 10/28/2021
Date Signed: 10/28/2021 11:17:07 AM

Document Has Been Signed on 10/28/2021 11:17 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:OUSD - STONEHURSTFACILITY NUMBER:
010206139
ADMINISTRATOR:OFELIA ASENCIOS-MENDOZAFACILITY TYPE:
850
ADDRESS:901 - 105TH AVENUETELEPHONE:
(510) 639-3382
CITY:OAKLANDSTATE: CAZIP CODE:
94603
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 42DATE:
10/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kianga LeeTIME COMPLETED:
11:25 AM
NARRATIVE
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LPA Lisa Dyer met with Kianga Lee for a Case Management inspection. Present today: the director, 9 teachers/staff, and 42 preschool children.
It was disclosed that Staff were not completing Daily Inspections for Illness, and an Unusual Incident occurred that staff failed to report to Licensing.

During the inspection, reporting requirements and daily inspections were discussed.

The attached type B deficiencies are cited today and must be corrected by the due date. This report must be available for public review for 3 years. Director was provided a copy of their appeal rights.

An exit interview was conducted and the report was discussed. A site visit notice was posted.
SUPERVISORS NAME: Phyllis Dyer
LICENSING EVALUATOR NAME: Phyllis Dyer
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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Document Has Been Signed on 10/28/2021 11:17 AM - It Cannot Be Edited


Created By: Phyllis Dyer On 10/28/2021 at 10:13 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: OUSD - STONEHURST

FACILITY NUMBER: 010206139

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2021
Section Cited
CCR
101226.1(a)

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Daily Inspection for Illness. The licensee shall be responsible for ensuring that children with obvious symptoms of illness including, but not limited to, fever or vomiting, are not accepted.

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By 11/15/21, a written plan of action will be sent to Licensing detailing the steps staff will take (in training) to ensure a daily inspection is performed prior to the acceptance of children into care.
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This requirement is not met as evidenced by interviews. Children do not receive a Daily Inspection for Illness prior to acceptance into the center. This poses a potential health risk to the Health and Safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type B
11/15/2021
Section Cited
CCR101212(d)(1)(c)

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Reporting Requirements. Each licensee or applicant shall furnish to the Department reports…any unusual incident …that threatens the physical or emotional health or safety of any child…
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Licensee will call CCL today to report incident; and submit report within 7 days. In the future, Licensing will be contacted by phone within 24 hours when Unusual Incidents occur per regulations.
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This requirement was not met as evidenced by interview and record review: director did not report an Unusual Incident that occurred at the facility to CCL. This poses an potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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:Phyllis Dyer
LICENSING EVALUATOR NAME:Phyllis Dyer
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021


LIC809 (FAS) - (06/04)
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