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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010211918
Report Date: 04/23/2025
Date Signed: 04/23/2025 10:38:32 AM

Document Has Been Signed on 04/23/2025 10:38 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:LARPD EXTENDED STUDENT SERVICES - JACKSONFACILITY NUMBER:
010211918
ADMINISTRATOR/
DIRECTOR:
RACHEL KARKAZISFACILITY TYPE:
840
ADDRESS:554 JACKSON AVENUETELEPHONE:
(925) 960-2463
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 40DATE:
04/23/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:45 AM
MET WITH:Rachel KarkazisTIME VISIT/
INSPECTION COMPLETED:
10:50 AM
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On April 23, 2025, Licensing Program Analyst (LPA) Simerjit Kaur conducted an UNANNOUNCED SITE INSPECTION for Title 5 school age program. LPA Kaur met with Director Rachel Shelnut Karkazis. LPA Kaur toured the facility. The facility is located on the campus of Jackson Elementary School. The campus also has Cape Head Start Program located adjacent to facility. The Director is aware the school program may not commingle with the Cape Head Start and elementary school. The facility operates from Monday through Friday 7:00 AM - 8:30 AM, and 1:30 PM - 6:00 PM. During school district breaks, the facility operates Monday through Friday 7:00 AM - 6:00 PM.

The center consists of Room A, and Room B, Room 32, Multipurpose room, office, combined bathroom for boys and girls, outside play ground, 2 kitchens and 2 staff bathroom. The facility has adequate heating and lighting. There is running water, soap, and paper towels available for children to wash and dry their hands. The center provide snacks and the weekly menu is posted outside the door. During summer, the children will bring their own lunch. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children were inaccessible during the inspection today. The center is equipped with a First Aid Kit, working telephone, carbon monoxide detector, pull down fire alarm and fire extinguishers. Alarm system is operated by Jackson Elementary School. There is drinking water readily available to children indoors and outdoors. The floors were free of tripping hazards during today's inspection. The storage containers for solid waste have tight-fitting covers.
The classrooms are equipped with age appropriate tables and chairs. There is adequate storage for children's belongings. There are school materials and art supplies stored in the storage cabinet. The facility utilize the outdoor playground with Jackson Elementary School. Outdoor activity space and playground equipment was observed to be safe during today's inspection. There is cushioning underneath the anchored play structure.
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NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Simerjit Kaur
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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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: LARPD EXTENDED STUDENT SERVICES - JACKSON
FACILITY NUMBER: 010211918
VISIT DATE: 04/23/2025
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Per director, there are currently children on any medication and LPA reviewed the IMS plan along with storage of medications. The first aid kit is available in the classroom B. Sign-in and sign-out logs were reviewed to verify census and signatures. LPA reviewed staff file and children files. There are no bodies of water accessible to children. Per director, there are no firearms on the premises. All storage areas for poisons are locked.

Director was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting https://mandatedreporterca.com/. Personnel and facility roster must be properly maintained, and fire/disaster drills must be conducted at least every six (6) months and documented.

Director was reminded that California law requires facilities to report unusual incidents and/or injuries to children in care, to the child's parents, and to the Department within 24 hours by phone, fax, or email. Within seven (7) days from the incident, facilities must submit the Unusual Incident/Injury form (LIC 624) to the Department. LPA informed Director that all forms can be downloaded at www.ccld.ca.gov.

Director was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to also email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. 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.

Director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Center Sections 101173 and 101226. 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/childqanda.htm.

Deficiency cited during the inspection. This report shall remain on file for 3 years. A Notice of Site Visit was provided to the facility director. Appeal rights provided. Exit interview was conducted.

NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Simerjit Kaur
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/23/2025 10:38 AM - It Cannot Be Edited


Created By: Simerjit Kaur On 04/23/2025 at 10:10 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: LARPD EXTENDED STUDENT SERVICES - JACKSON

FACILITY NUMBER: 010211918

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101227(a)(19)
Food Service
(a) In child care centers providing meals to children, the following shall apply: (19) All food shall be protected against contamination. Contaminated food shall be discarded immediately.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, facility has expired 2 Trisuit boxes stored in kitchen, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2025
Plan of Correction
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The Director will review all food items and immediately will discard all expired food. The director will check the food periodically to ensure all expired food items are within the expiration date. The director shall send plan of action to LPA by 5/7/2025.
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.
Jason Jang
NAME OF LICENSING PROGRAM MANAGER:
Simerjit Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
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