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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412462
Report Date: 09/06/2023
Date Signed: 09/06/2023 12:01:29 PM

Document Has Been Signed on 09/06/2023 12:01 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 - GLENMOORFACILITY NUMBER:
013412462
ADMINISTRATOR:PITRUZZELLO, HEATHERFACILITY TYPE:
840
ADDRESS:4620 MATTOS DRIVETELEPHONE:
(510) 744-0772
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 15DATE:
09/06/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Jayjay NagayoTIME COMPLETED:
12:10 PM
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A Case Management Inspection was conducted on this date 09/06/2023 at 11:20AM by Licensing Program Analyst (LPA) Melanie Otsuji. LPA met with Facility Representative, Jayjay Nagayo. An application was submitted for a Capacity Increase. Facility is requesting to increase from 60 school aged children to 115 school aged children. The school age program is located on Glenmoor Elementary School campus. The program is currently utilizing the Multi-Purpose Room and Adventure Time portable. Hours of operation are from 7:00AM-8:30AM and 11:30AM - 6PM (Mon/Tues/Thurs/Fri). Also present during today's visit were 3 additional staff members and 15 school aged children. A health and safety inspection was conducted inside and outside.

INDOORS: EXEMPT
OUTDOORS: EXEMPT

This facility is exempt from square footage and bathroom requirements. Facility utilizes the Elementary School playground, blacktop and grassy area. Facility understands that at no time should the Adventure Time children commingle with the Elementary School children. Drinking water is available inside and outside by way of water fountains and bottles brought from home. Facility provides AM/PM snacks. Menus are posted. Facility has a functioning carbon monoxide detector, smoke detector and fire extinguisher. Facility has a sign in/out sheet that allows ample space for full legal signature and records time and date.

An approved Fire Clearance was received on 08/31/2023 from Fremont Fire Department for 115 school aged children.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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 - GLENMOOR
FACILITY NUMBER: 013412462
VISIT DATE: 09/06/2023
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All licensing required documents are posted. Per facility representative, all Opening and Closing staff have current Pediatric CPR/First Aid. This facility plans to provide Incidental Medical Services – IMS. An updated Plan of Operation that includes IMS must be submitted to the Department when any changes are made. 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.

The center was found to be clean, safe, sanitary and in good repair.

There are no deficiencies cited during today's visit. A license with approval for 115 school aged children operating out of the Adventure Time Portable and Multi-Purpose Room will be issued effective, 9/6/2023.

An exit interview was conducted with facility representative, Jayjay Nagayo.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC809 (FAS) - (06/04)
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