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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013411130
Report Date: 10/13/2021
Date Signed: 10/13/2021 05:31:19 PM

Document Has Been Signed on 10/13/2021 05:31 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 - JENSEN RANCHFACILITY NUMBER:
013411130
ADMINISTRATOR:FERN, TIFFANYFACILITY TYPE:
840
ADDRESS:20001 CARSON LANETELEPHONE:
(510) 728-9933
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94552
CAPACITY: 90TOTAL ENROLLED CHILDREN: 46CENSUS: 32DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Jessica DennisTIME COMPLETED:
05:45 PM
NARRATIVE
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On 10/13/2021 at 01:59pm, Licensing Program Analyst (LPA) Jonathan Williams met with Jessica Dennis (Director) for a Required 1-Year Inspection. Present for this inspection are the Director, one teacher, two teacher aides, and 32 school aged children in care. Facility operating hours are 7am-10am M-F, M-Th 1:30pm-6pm, and F 12:30pm-6pm. The facility was toured to conduct a health and safety inspection.

At 2:00pm, LPA toured the facility classroom. The facility operates in a portable on the site of Jensen Ranch Elementary School. The classrooms are 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, in operable condition, and free of loose, sharp, or pointed parts. Snack food is protected from contamination and, per staff, contaminated food is discarded immediately. Food/beverages capable of rapid spoiling are properly stored. Uncontaminated drinking water is available to children inside and outside the facility. LPA observed adequate amounts of paper towels and hand soap available to children in the bathroom during today's inspection. No cleaning supplies were observed to be accessible to children during today's inspection.

At 4:48pm, LPA reviewed sign in/sign out sheet. LPA observed 37 signatures out of 37 children present in the facility during today's inspection.

At 4:52pm, LPA toured the outdoor play area. All play equipment was observed to be operable and age-appropriate during this inspection. Areas around swings, slides, and high climbing equipment have cushioning material to absorb falls. There are no pools, hot tubs, ponds, or any other bodies of water accessible to children during today's inspection.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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 10/13/2021 05:31 PM - It Cannot Be Edited


Created By: Jonathan Williams On 10/13/2021 at 04:58 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 - JENSEN RANCH
FACILITY NUMBER: 013411130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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. Staff members S1 and S3 do not have required immunizations on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2021
Plan of Correction
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Director shall obtain required immunization records for S1, S3, and S4. Director shall submit said documentation to LPA by the POC due date.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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. Staff members S3 and S4 are missing required Mandated Reporter training certificates. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2021
Plan of Correction
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Director shall obtain required Mandated Reporter training certificates for S3 and S4. Director shall submit said documentation to LPA by the POC due date.
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:Wynn Norona
LICENSING EVALUATOR NAME:Jonathan Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/13/2021 05:31 PM - It Cannot Be Edited


Created By: Jonathan Williams On 10/13/2021 at 04:58 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 - JENSEN RANCH
FACILITY NUMBER: 013411130

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(d)
Personnel Records
(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review.

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. Packet of all required personnel records for S4 are not present at the facility for review by LPA. This which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2021
Plan of Correction
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Director shall obtain the required personnel records for S4 and submit proof to LPA by the POC due date.
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:Wynn Norona
LICENSING EVALUATOR NAME:Jonathan Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2021


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 - JENSEN RANCH
FACILITY NUMBER: 013411130
VISIT DATE: 10/13/2021
NARRATIVE
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The facility has two fully charged 2A10BC fire extinguishers, working smoke detector, working carbon monoxide detector, and working telephone. At least one staff member has current CPR/1st Aid certificate. The facility is in ratio today. Children's files and staff files were reviewed for proper documentation. All required forms are posted in public view. Facility roster was obtained.

Incidental Medical Services (IMS) policy was discussed. This facility provides IMS to children in care. Facility is following 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.”

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.

Director 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 Director that all forms can be downloaded at www.ccld.ca.gov and encouraged the Director to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The Director 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.

There are deficiencies cited. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director. Appeal rights were provided to the Director and the signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC809 (FAS) - (06/04)
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