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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010209547
Report Date: 03/19/2025
Date Signed: 03/19/2025 01:12:06 PM

Document Has Been Signed on 03/19/2025 01:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:BETH SHOLOM PRESCHOOLFACILITY NUMBER:
010209547
ADMINISTRATOR/
DIRECTOR:		CHASE, AMANDAFACILITY TYPE:
850
ADDRESS:642 DOLORES AVENUETELEPHONE:
(510) 357-8505
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 49TOTAL ENROLLED CHILDREN: 49CENSUS: 43DATE:
03/19/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Amanda ChaseTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
NARRATIVE
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On March 19th, 2025 at 8:55 AM, Licensing Program Analyst (LPA) Michael Mathew conducted an unannounced Annual/Random inspection. LPA met with director Amanda Chase and advised her the purpose of the inspection. LPA was provided a tour of the facility inside and out. There were 43 children in care and 8 staff at the time of the inspection.

LPA observed required licensing documents mounted on the walls throughout the facility. The facility does not provides lunch or snacks. Parents provided snacks and lunch for their child. Fire drill was last conducted on 3/18/25. The center has three (3) classrooms available. At the time of inspection, all classrooms were in use. LPA observed enough restrooms available for children in care. LPA did not observe any hazards/toxins items accessible to children in care. There are no guns/weapons or ammunition at the facility. LPA observed no bodies of water. Each of the classrooms have age-appropriate toys and furniture readily accessible for children. Facility provides children sleeping cots during nap time. LPA observed The outdoor playground has ample amount of space for children to play. LPA observed tan bark in the play area to help protect the children when they fall. LPA observed the playground has age-appropriate toys and structures available for children to use. The playground has an ample amount of shade available. Facility provides water, and the children have water bottles with there names on it for use.

A sampling of children and staff records were reviewed. LPA observed children's files to be complete and current. Currently the facility does not have children that require Incidental Medical services (IMS). LPA observed staff files to be incomplete complete. LPA observed all staff members with a valid Mandated reporter certificate. LPA observed at least one person with a valid CPR/first aid certificate. LPA verified SB792 Child Care Adult Immunization and Tuberculosis requirements.
Continued 809-C
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Michael Mathew
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: BETH SHOLOM PRESCHOOL
FACILITY NUMBER: 010209547
VISIT DATE: 03/19/2025
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Director Amanda Chase was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated

LPA discussed the safe sleep regulations with Director Amanda Chase and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

1 type B deficiency were cited in today visit.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted, appeal rights were given, and report was reviewed with Director Amanda Chase

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Michael Mathew
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2025
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Document Has Been Signed on 03/19/2025 01:12 PM - It Cannot Be Edited


Created By: Michael Mathew On 03/19/2025 at 12:33 PM
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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: BETH SHOLOM PRESCHOOL
FACILITY NUMBER: 010209547

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. During record review LPA observed that S1 and S2 did not have the LIC 503 in the staff file.
POC Due Date: 03/27/2025
Plan of Correction
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Director agreed to send completed LIC 503 by end of day Thursday 3/27/25.
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:Wynn Norona
LICENSING EVALUATOR NAME:Michael Mathew
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


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