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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412462
Report Date: 05/01/2024
Date Signed: 05/01/2024 03:12:30 PM

Document Has Been Signed on 05/01/2024 03:12 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 CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:ADVENTURE TIME - GLENMOORFACILITY NUMBER:
013412462
ADMINISTRATOR/
DIRECTOR:		PITRUZZELLO, HEATHERFACILITY TYPE:
840
ADDRESS:4620 MATTOS DRIVETELEPHONE:
(510) 744-0772
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 115TOTAL ENROLLED CHILDREN: 90CENSUS: 70DATE:
05/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Christina Brown - DirectorTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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On May 1, 2024, 2:10pm Licensing Program Analysts (LPAs) Randy Miranda and Briana Plumboy arrived at the facility to conduct an unannounced case management visit that was reported to CCLD on 04/29/2024. Present for the inspection was 70 school age children and 9 staff. LPAs met with director, Christina Brown. LPAs toured the facility and interviewed the director. According to Title 22, Division 12, Chapter 1, Article 06, Section 101212(d) 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.

See 809-D for deficiency cited during today's inspection. Appeal rights provided and discussed. Exit interview conducted and report was reviewed with director Christina Brown.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Randy Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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 05/01/2024 03:12 PM - It Cannot Be Edited


Created By: Randy Miranda On 05/01/2024 at 02:46 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 - GLENMOOR
FACILITY NUMBER: 013412462

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2024
Section Cited
CCR
101212(d)

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 101212(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, 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 containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
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On or before 04/03/2024, licensee will watch the "Child Care Reporting Requirements" video on the ccld.ca.gov website and provide LPA Miranda a summary of the video.
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This requirement is not met as evidenced by: Based on record review, the licensees did not comply with the section cited above by not reporting to the Department by telephone or fax within the Department's next working day and during its normal business hours which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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:Randy Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


LIC809 (FAS) - (06/04)
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