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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211776
Report Date: 05/03/2024
Date Signed: 05/03/2024 04:32:25 PM

Document Has Been Signed on 05/03/2024 04:32 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:HIS GROWING GROVEFACILITY NUMBER:
010211776
ADMINISTRATOR/
DIRECTOR:		JENNIFER YOUNGBLOODFACILITY TYPE:
830
ADDRESS:2490 GROVE WAYTELEPHONE:
(510) 581-5088
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 24TOTAL ENROLLED CHILDREN: 21CENSUS: 19DATE:
05/03/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Jennifer YoungbloodTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 05/03/2024 at 8:30am, Licensing Program Analyst (LPA) Christina Uribe & Regional Manager (RM) Jennifer Pare conducted an Unannounced Annual Required Inspection. LPA met with Site Director, Jennifer Youngblood, also present at the time of the inspection were 7 staff & 19 children. The facility is within ratio & capacity compliance today. LPA provided facility representative the Entrance Checklist (LIC 125). The facility was toured to conduct a Health and Safety inspection. The facility currently operates 7:30am-5:30pm, Monday-Friday in one classroom.

Classrooms: The classroom was inspected for age-appropriate furnishings, equipment, & adequate storage for children’s belongings. LPA observed the cleanliness of floors & surfaces, the presence of a fully functional carbon monoxide detector, smoke detector/fire alarms, and a fully charged 3A40BC fire extinguisher that is accessible throughout the facility. The changing tables are clean and within arm’s reach of a functional sink. The center is equipped with a fully stocked first-aid kit and available in the classrooms.

Safe Sleep: All cribs were inspected for model compliance, inside of crib only consisted of a fitted mattress and no other items in or attached to crib. LPA observed Safe Sleep Plan & sleep record log for 15-minute checks for each child in attendance.

Food Service Areas: All children’s individual food items are labeled and properly stored. All center provided food items are properly labeled & stored separately from cleaning supplies. Food prep area is clean, adequately equipped, & free from hazardous materials. Snack menu is posted one week in advance, available for review, & dated. Solid waste bins are equipped with tight fitting lid.

Page 1 of 4 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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: HIS GROWING GROVE
FACILITY NUMBER: 010211776
VISIT DATE: 05/03/2024
NARRATIVE
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Outdoor Play Area: There are no bodies of water, or free-standing water accessible to children. There are age appropriate outdoor toys and materials for the children. The playground outside is fenced and all equipment and surfaces are free from hazards. There is ample shade available outside. The ground beneath the play structures are tanbark and sufficient soft padding for safety.

Records: All individuals subject to criminal record review have a clearance and have been associated to the facility. LPA reviewed 6 children’s files and 7 staff files. LPA reviewed the facility roster & personnel report and copies were obtained. LPA reviewed transcripts and signed the Evaluation of Teacher Qualifications (LIC 9095) form for 2 staff members. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Mandated Reporter certificates were reviewed. Director’s CPR/First-Aid Certificate is current and expires on 04/15/25. Director was reminded of their responsibility to renew CPR/First Aid and Mandated Reporter certificates every two years. The center is in compliance with sign in and out procedure. Emergency Drills are recorded and performed at least every six months. Per facility representative, there are no firearms on the premises. All required documents are posted in a publicly accessible area.

CCLD Inspection Process: To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Criminal Record Clearance: Director 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.

Page 2 of 4 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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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: HIS GROWING GROVE
FACILITY NUMBER: 010211776
VISIT DATE: 05/03/2024
NARRATIVE
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One Deficiency & 4 Advisory Notes Issued during today's inspection:
  • Type B Violation: During record review, It was found that 5 of the 6 infant files did not have a updated Needs & Services Plan within the previous 3 months. Needs & Services Plans must be updated at least once every quarter.
  • Advisory Note (TV): One child's medications did not have their original packaging and/or the prescription label.
  • Advisory Note (TV): One child's medications were listed on one Parent Consent for Administration of Medication (LIC 9221). One LIC 9221 form is needed for each type of medication.
  • Advisory Note (TV): During record review, it was found that 3 out of the 6 children's files need an updated immunization record.
  • Advisory Note (TV): Some children's files were found to be incomplete and/or inaccurate information. Two children's Admission Agreement forms had the child's wrong birth year documented. Two children's Personal Rights (LIC 613A) forms did not have the child's name on them.

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. Appeal rights were given and reviewed. Exit interview conducted and report was reviewed with the licensee, Jennifer Youngblood.

Page 4 of 4 ***End of Report***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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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: HIS GROWING GROVE
FACILITY NUMBER: 010211776
VISIT DATE: 05/03/2024
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Lead Testing: Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Safe Sleep: LPA discussed the safe sleep regulations with director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed director 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.

Incidental Medical Services (IMS): This facility does provide Incidental Medical Services (IMS). LPA inspected storage of medications and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at http://www.ada.gov/resources/child-care-centers/.

MyChildCarePlan.org: Director was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Unusual Incident/Student Injury Report: Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone to the regional office at 510-622-2602 and the written report, LIC 624, within 7 business days.

Page 3 of 4 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
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Document Has Been Signed on 05/03/2024 04:32 PM - It Cannot Be Edited


Created By: Christina Uribe On 05/03/2024 at 03:13 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: HIS GROWING GROVE
FACILITY NUMBER: 010211776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.3(a)
Modifications to Infant Needs and Services Plan
(a) The written infant needs and services plan shall be updated at least quarterly, or as often as necessary to assure its accuracy.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 5 out of the 6 children's files reviewed did not have an updated Needs & Services Plan dated within the last 3 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Facility will ensure that all infant files have an updated Needs & Services Plan that is dated within the previous 3 months at all times. LPA Uribe will return to the facility for Plan of Correction visit after the due date of 06/03/2024 to verify that the facility has met the requirement.
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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


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