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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010210478
Report Date: 08/16/2023
Date Signed: 08/16/2023 03:45:15 PM

Document Has Been Signed on 08/16/2023 03:45 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CONGREGATION BETH ISRAEL-GAN SHALOMFACILITY NUMBER:
010210478
ADMINISTRATOR:EMMA SCHNURFACILITY TYPE:
850
ADDRESS:2230-32 JEFFERSON STREETTELEPHONE:
(510) 848-3298
CITY:BERKELEYSTATE: CAZIP CODE:
94703
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 0DATE:
08/16/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Emma SchnurTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts Cherie Acosta and Sikia Blue conducted an unannounced case management visit. LPAs met with Director Emma Schnur.

Director self reported an incident that occurred on 7/14/23. It was reported that there were 13 children, 1 teacher and 1 teacher aide on the play yard. The teacher aide stepped into the classroom to get something form the classroom which left the teacher out of ratio. It was reported the teacher was out of ratio for approximately 5 seconds.

See 809-D for deficiencies cited during today's visit.

The facility was previously cited for being out of ratio on 4/25/23. A civil penalty of $250.00 is assessed today.

Notice of Site Visit was provided and must be posted for 30 day.

Exit interview and report reviewed with Emma Schnur
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
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 08/16/2023 03:45 PM - It Cannot Be Edited


Created By: Cherie Acosta On 08/16/2023 at 03:00 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CONGREGATION BETH ISRAEL-GAN SHALOM
FACILITY NUMBER: 010210478

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/21/2023
Section Cited
CCR
101216.3(a)

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Teacher-Child Ratio. There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.
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Director shall provide proof of staff training on ratio. Director shall submit the training agenda and proof of staff attendance to CCL by 8/21/23.
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This requirement was not met as eviendced by: a teacher was supervising 13 children alone when the aide stepped into the classroom which poses a potential 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.


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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Cherie Acosta
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
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