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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010214924
Report Date: 11/14/2022
Date Signed: 11/14/2022 01:01:19 PM

Document Has Been Signed on 11/14/2022 01:01 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:ADVENTURE TIME - WARWICKFACILITY NUMBER:
010214924
ADMINISTRATOR:SANTOS, LINDAFACILITY TYPE:
840
ADDRESS:3375 WARWICK ROADTELEPHONE:
(510) 797-6122
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY: 108TOTAL ENROLLED CHILDREN: 80CENSUS: 14DATE:
11/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Linda SantosTIME COMPLETED:
01:20 PM
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On 11/14/2022 at 9:00AM, Licensing Program Analyst (LPA) Kelly Phan met with Linda Santos (site director) for an unannounced Required 1-Year Inspection. Present for this inspection are three fingerprint cleared and associated staff members and 14 school aged children in care. Facility operating hours are 7AM-6PM Monday to-Friday. The facility was toured to conduct a health and safety inspection.

At 9:15AM, LPA toured the facility classroom. The facility operates in a portable on the site of Warwick Elementary School. The classroom is tidy and clean with heating and ventilation for safety and comfort. There are safe age-appropriate toys and learning materials available to children throughout the classroom. All hazardous materials and toxins including disinfectants and cleaning solutions were observed to be made inaccessible to children during today's inspection. Furniture accessible to children was observed to be age-appropriate. Food, beverages, and medications are kept in refrigerator; all food and drinks are in original containers and are not expired. The facility is providing filtered drinking water with disposable cups to children inside and outside the facility. LPA reviewed storage and documentation of children's medications; all medications are made inaccessible to children as it is kept in a locked cabinet and medications are in original containers with unaltered instructions and are not expired. LPA recommends the director to use LIC 9221 (Parent Consent form for Administrating Medications) to maintain both prescription and non-prescription medications. There is one fully charged 3A40BC fire extinguisher, two pull-down fire alarms, working smoke detector that was last checked on 11/30/2021 by Adatto Security and Communications; per program director the fire inspector usually comes when there are no children present and will follow up for their next inspection. There is also a working carbon monoxide detector and working telephones. All required forms are posted in public view, including menus. Children are able to bring their own food or the facility will provide meals. LPA also reviewed the sign in/out sheet and found that there are 14 signatures out of 14 children present today. SEE LIC 809 C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ADVENTURE TIME - WARWICK
FACILITY NUMBER: 010214924
VISIT DATE: 11/14/2022
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At 10:00AM, LPA toured the facility bathroom. The facility is sharing bathrooms and two play structures with the Warwick elementary school children. Per director, the facility will uses the play areas during Wednesdays at 1:30PM and other school days at 2:45PM when the elementary school is not playing on it. Areas have cushioning material to absorb falls. LPA observed adequate amounts of paper towels and hand soap available to children in the two separated bathroom during today's inspection. There is also a separate staff bathroom located on the premises. No cleaning supplies were observed to be accessible to children during today's inspection. There are no pools, hot tubs, ponds, or any other bodies of water accessible to children. The facility last conducted their fire drill on October 14, 2022.

At 10:30AM, LPA reviewed 5 staff files and found that Staff#3 was missing documentations such as LIC 501 (Personnel Report), immunizations, mandated reporter training, and had an incomplete LIC 503 (Health Screening form). Staff #5 also had an incomplete health screening form. Six children files were also reviewed for completion; All children files were missing LIC 627 (Consent for Emergency Medical Treatment) and LIC 700 (Identification and Emergency Information); Facility created their own versions, however director was advised to use the required licensing forms found on CDSS website.

There was 2 deficiencies were cited for today's inspection
Type B - all six children file were missing required licensing forms - LIC 627 and 700
Type B - Staff#3 was missing documentations such as LIC 501 (Personnel Report), immunizations, mandated reporter training, and had an incomplete LIC 503 (Health Screening form); Staff #5 also had an incomplete health screening form

Appeal rights and 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 $100.00. Exit interview conducted and report was reviewed with site director, Linda Santos SEE LIC 809 C



SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC809 (FAS) - (06/04)
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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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ADVENTURE TIME - WARWICK
FACILITY NUMBER: 010214924
VISIT DATE: 11/14/2022
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Incidental Medical Services (IMS) policy was discussed. This facility provides IMS to children in care. The facility is following and have developed IMS plan on file. When any changes to the IMS plan is made, an updated Plan for Providing IMS must be submitted to the Department. 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.”

Facility Representative was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.

Facility Representative was reminded that California Law requires licensed Child Care Centers 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 by phone, fax, or electronic mail. LPA informed the Facility Representative that all forms can be downloaded at www.ccld.ca.gov and encouraged the Facility Representative to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.



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.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2022 01:01 PM - It Cannot Be Edited


Created By: Kelly Phan On 11/14/2022 at 12:05 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: ADVENTURE TIME - WARWICK
FACILITY NUMBER: 010214924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above there were two staff files that had incomplete or missing LIC 503 - Health Screening form, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2022
Plan of Correction
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Director will send corrections to LPA via email before or on 12/14/2022
Type B
Section Cited
CCR
101221(b)
Child's Records
(b) Each record shall contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above during a file review of six children files were missing several required licensing forms including LIC 627 and 700, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2022
Plan of Correction
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Director will send corrections to LPA via email before or on 12/14/2022
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:Kelly Phan
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022


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