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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013411130
Report Date: 08/14/2025
Date Signed: 08/14/2025 03:23:21 PM

Document Has Been Signed on 08/14/2025 03:23 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:ADVENTURE TIME - JENSEN RANCHFACILITY NUMBER:
013411130
ADMINISTRATOR/
DIRECTOR:		JESSICA ANDREWSFACILITY TYPE:
840
ADDRESS:20001 CARSON LANETELEPHONE:
(510) 728-9933
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94552
CAPACITY: 90TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
08/14/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Mimi Albert- Program DirectorTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
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On 8/14/25, Licensing Program Analyst (LPA) Briana Plumboy met with Director Jessica Andrews for an unannounced annual/random inspection. Present for the inspection was 5 staff, 1 volunteer, and 12 school age children. During the inspection at 2:45pm, Program Director Mimi Albert arrived at the center. The facility is located in a portable at the far end of Jensen Ranch Elementary school and has its own entrance. The center was toured for a health and safety inspection. The facility currently operates 7:00am-8:15am in the mornings & 1:00pm-6:00pm in the evenings, Monday-Thusday and 7:00am-8:15am in the mornings and 12:00pm-6:00pm in the afternoon on Fridays in one classroom. The center operates in conjunction with the Castro Valley School District school year calendar.

There is adequate storage for children's belongings. It was observed the cleaning products and medicines were inaccessible to the children during today's inspection. Furniture is in good condition. The toilets and faucets are in working order. The food preparation area and storage areas are clean and in sanitary condition. All storage containers for solid waste have tight fitting covers. The facility provides both morning and afternoon snacks. A menu is posted and visible for review. Drinking water is available both indoors and outdoors. The facility has a carbon monoxide detector, smoke detector, fire extinguishers and first aid kit. The children are using the school yard for outdoor activities. The school play structure closest to the portable is used by the children. Visual supervision is provided while children are playing. Climbing equipment is properly anchored to the ground with adequate and appropriate cushioning material to absorb falls. There is a shaded area provided for the children. A physical census was taken of all children present and crossed referenced with the sign in and out sheets. LPA verified staff taking a census and matching it with the sign in/out sheet.

See 809-C for continuance

NAME OF LICENSING PROGRAM MANAGER: Wynn Norona
NAME OF LICENSING PROGRAM ANALYST: Briana Plumboy
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2025
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.

LIC809 (FAS) - (09/23)
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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: ADVENTURE TIME - JENSEN RANCH
FACILITY NUMBER: 013411130
VISIT DATE: 08/14/2025
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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 no 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.
NAME OF LICENSING PROGRAM MANAGER: Wynn Norona
NAME OF LICENSING PROGRAM ANALYST: Briana Plumboy
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2025
LIC809 (FAS) - (06/04)
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