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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013411745
Report Date: 01/23/2023
Date Signed: 01/23/2023 02:53:17 PM

Document Has Been Signed on 01/23/2023 02:53 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:CHABOT COLLEGE, CHILDREN'S CENTERFACILITY NUMBER:
013411745
ADMINISTRATOR:ORTIZ, CARMENFACILITY TYPE:
850
ADDRESS:25555 HESPERIAN BOULEVARDTELEPHONE:
(510) 723-6684
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 120TOTAL ENROLLED CHILDREN: 31CENSUS: 27DATE:
01/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Carmen OrtizTIME COMPLETED:
02:40 PM
NARRATIVE
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On 1/23/2023 at 10:24am Licensing Program Analyst Morgan Pringle met with Director Carmen Ortiz for an Unannounced Case Management Visit for two (2) unusual incidents that happened at the facility on two (2) separate occasions. Present during the visit were five (5) staff and twenty-seven (27) children. LPA toured the facility and conducted an interview with the facility Director. The Title V facility operates on the Chabot College Campus in building 3500. The facility operates from 7:30am – 5:00pm, Monday – Friday.

On 1/5/2023 an incident occurred at the facility involving a child who suffered a medical emergency and needed immediate emergency attention. The facility followed all protocols that were set in place by Chabot College, and the child was taken to the hospital via ambulance. After the incident occurred, the facility failed to report the incident to Community Care Licensing on the next business day, which is required per California State Title 22 Regulations. Director stated that she was unaware of the timing for licensing reporting requirements.

On 1/17/2023 four (4) preschool age children in preschool one (1) left the playground and entered the empty Preschool 3 classroom with no supervision. There were two (2) teachers supervising ten (10) children outside. One (1) teacher brought two (2) children into the bathroom. Director stated that the teacher who remained outside noticed the lowered amount of children outside but assumed the four (4) children were with the teacher that had entered the bathroom. The Facility Resource Coordinator found the four (4) children playing inside of the classroom unsupervised. Director stated that the four (4) children were all fine without any harm when found and were unsupervised for about five (5) minutes.

Type A Deficiency Cited


· Lack of Supervision
Type B Deficiency Cited
· Failure to report unusual incident during next business day.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: CHABOT COLLEGE, CHILDREN'S CENTER
FACILITY NUMBER: 013411745
VISIT DATE: 01/23/2023
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LPA Morgan Pringle informed Director Carmen Ortiz that this report dated 1/23/2023 document(s) one (1) Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Pringle informed the Director to provide a copy of this licensing report dated 1/23/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director Carmen Ortiz.

This is an amended version of the original report from 1/23/2023. Document was amended on 2/28/2023 and signed by LPA Pringle and Director Carmen Ortiz on 3/01/2023.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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Document Has Been Signed on 01/23/2023 02:53 PM - It Cannot Be Edited


Created By: Morgan Pringle On 01/23/2023 at 12:47 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: CHABOT COLLEGE, CHILDREN'S CENTER
FACILITY NUMBER: 013411745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited
CCR
101229(a)(1)

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(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation. This requirement is not met as evidenced by:
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By 1/25/2023 Director agreed to submit a written plan to LPA Pringle on how the facility staff will ensure complete supervision of all children in care at all times. Starting 1/24/2023, Director will implement a "face-to-name" sheet that all facility staff will complete for the next four (4) days.
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Four (4) children were inside an unsupervised classroom for about 5 minutes. This poses an immediate risk to the health and safety of children in care.
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Director will send a copy of the completed sheets to LPA Pringle.

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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:Jason Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/23/2023 02:53 PM - It Cannot Be Edited


Created By: Morgan Pringle On 01/23/2023 at 12:59 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: CHABOT COLLEGE, CHILDREN'S CENTER
FACILITY NUMBER: 013411745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2023
Section Cited
CCR
101212(d)

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(d) Upon the occurrence...a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report...shall be submitted to the Department within seven days following the occurrence of...event.
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Faciity Director will submit to LPA Pringle a statement explaining the requirements for reporting unsual incidents and who is in charge of reporting incidents to CCL in her absense.
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This requirement is not met as evidenced by: Facility Director failed to report an unusual incident where a child suffered a medical emergency and 911 was called which poses a potential risk to the health and safety 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:Jason Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2023


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