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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010214881
Report Date: 03/27/2024
Date Signed: 03/27/2024 02:28:17 PM

Document Has Been Signed on 03/27/2024 02:28 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:BUSD - HOPKINS STREETFACILITY NUMBER:
010214881
ADMINISTRATOR:ROBINSON, K & CARRIEDO, M.FACILITY TYPE:
850
ADDRESS:1810 HOPKINS STREETTELEPHONE:
(510) 644-8939
CITY:BERKELEYSTATE: CAZIP CODE:
94707
CAPACITY: 140TOTAL ENROLLED CHILDREN: 140CENSUS: 49DATE:
03/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:48 AM
MET WITH:Madeleine RoginTIME COMPLETED:
02:40 PM
NARRATIVE
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On March 27, 2024 Licensing Program Analyst (LPA) Indira Loza met with Interim Director Madeleine Rogin. Present during the visit were 49 children and 15 staff. The purpose of the visit was due to a self reported incident that was received in the Oakland Regional office on 3/19/24.

LPA conducted interviews regarding the incident that occurred on 3/18/24, where a staff left an empty vitamin capsule in an area accessible to children in care, and a child got the capsule, placed it in their lunch box, and took it home. Interviews indicated that the Aide was observed breaking open a capsule and pouring the contents on their food, stating they were taking their vitamins.

See LIC809-D for one Type B deficiency.

Exit interview conducted.
A copy of the report and appeal rights provided to Interim Director Madeleine Rogin.
Notice of Site Visit provided and must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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 03/27/2024 02:28 PM - It Cannot Be Edited


Created By: Indira Loza On 03/27/2024 at 01:22 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: BUSD - HOPKINS STREET
FACILITY NUMBER: 010214881

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/28/2024
Section Cited
CCR
101223(a)(2)

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(a) The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by:
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The Director shall come up with a plan to prevent this from occurring again and conduct a meeting with staff to review the prevention plan and send LPA Loza a sign in sheet from the meeting by April 26, 2024.
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Based on record review and interview, it has been determined that an Aide left a half of an empty vitamin capsule accessible to children, and a child took it home, which poses a potential risk to the health, safety, and personal rights of children in care.
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
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