<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211015
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:24:44 PM

Document Has Been Signed on 11/03/2023 02:24 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:LIVERMORE PLAYSCHOOLFACILITY NUMBER:
010211015
ADMINISTRATOR:ZAPIEN, ROBYNFACILITY TYPE:
850
ADDRESS:5261 EAST AVENUETELEPHONE:
(925) 447-6042
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 57DATE:
11/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Robyn ZapienTIME COMPLETED:
02:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On November 3, 2023, Licensing Program Analyst (LPA) Simerjit Kaur arrived to conduct UNANNOUNCED CASE MANAGEMENT INSPECTION for Preschool age program and met with Director Robyn Zapien. Present during the inspection are 57 preschool age children and 9 fingerprint cleared staff members.

The facility self reported incident on 10/11/23 and a copy of the Unusual Incident Report (UIR) was reviewed by LPA. Per the report, a staff member failed to make sure that all children were accounted for when going outside to upper playground for snack time. Per UIR, C1 was inside the classroom unsupervised for approximately 13 minutes. As a result, there was an Absence of Supervision, one child was left inside classroom without supervision. Although the facility states that the child was left inside alone for thirteen minutes, Title 22 Regulations, 101229(a)(1) states that no child(ren) shall be left without the supervision of a teacher at any time including visual supervision.

The facility must post this report for 30 days. The facility must give each parent of the children in care and future parents of newly enrolled children, for the next one year, a copy of this report. Parents are to sign an LIC 9224- Acknowledgment of Receipt of Licensing reports and this form shall be placed in each child's file. Failure to post report and or provide a copy of this report to parent's/authorized guardians can result in additional monetary assessments to the facility. LPA and director discussed in detail on how to prevent this from happening in the future.

This report must remain on file for 3 years. The Director was provided a copy of their appeal rights.

See 809D for Deficiency.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Simerjit Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/03/2023 02:24 PM - It Cannot Be Edited


Created By: Simerjit Kaur On 11/03/2023 at 01:18 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: LIVERMORE PLAYSCHOOL
FACILITY NUMBER: 010211015

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2023
Section Cited
CCR
101229(a)1

1
2
3
4
5
6
7
101229(a)1 The licensee shall provide care and supervision… No child(ren) shall be left without the supervision of a teacher at any time except as specified… Supervision shall include visual observation. This requirement was not met as evidence by:
1
2
3
4
5
6
7
The facility will submit a Plan of Correction in writing by indicating how they will ensure that children are always directly supervised and Staff will watch a video on Supervision on CCLD website. The director will be send Plan of correction to LPA by 11/6/23.
8
9
10
11
12
13
14
Based on interview and record review the facility did not ensure all children were accounted for at outside playground snack time and C1 was inside classroom unsupervised for 13 minutes, which poses an immediate risk to the health and safety of children in care.
8
9
10
11
12
13
14
The facility will receive a Civil Penalty Assessment in the amount of $500.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Jason Jang
LICENSING EVALUATOR NAME:Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2