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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412608
Report Date: 10/17/2022
Date Signed: 10/17/2022 03:57:51 PM

Document Has Been Signed on 10/17/2022 03:57 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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
013412608
ADMINISTRATOR:CATHERINE BOLLINGERFACILITY TYPE:
850
ADDRESS:4655 LASSEN ROADTELEPHONE:
(925) 455-1560
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY: 72TOTAL ENROLLED CHILDREN: 37CENSUS: 30DATE:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Jamie CzelusniakTIME COMPLETED:
03:47 PM
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On 10/17/2022 at 9:07am Licensing Program Analyst (LPA) Morgan Pringle met with Director Jamie Czelusniak, for an Unannounced Annual Inspection. During the inspection there were thirty (30) preschool children and five (5) staff present. Three classrooms, Preschool A, B, and C were toured for a health and safety inspection. There is another classroom that is licensed but currently not being used by the children. The facility operates from 6:30am – 6:00pm, Monday – Friday. This facility holds licenses for an infant (Facility #013412610) and school age (Facility #013412609) component as well.

The facility has ample age appropriate materials in the classrooms that were observed to be clean and in good condition. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. All napping equipment is properly stored, clean and free from defects. All bathrooms are clean and in proper working order. All children have access to clean drinking water in and outside of the classrooms. There are carbon monoxide detectors, smoke detectors and fully charged fire extinguishers on site. The outside play yard is fully fenced, clean, and free from hazards with plenty of shade. The play structure is sturdy and anchored into the ground. LPA did not observe any harmful or unattended bodies of water in or around the facility.



The facility is operating within its licensed capacity and is in ratio. All proper postings are made visible in the entry way of the facility. All food provided by the facility is properly stored and labeled. The kitchen and food preparation areas are clean and free from all hazards. All food at the facility is brought in by U.S. Foods. Facility provides breakfast, lunch and two (2) snacks per day. The fire/disaster drill log is complete with the last drill logged on 9/27/2022. LPA obtained the sign in/out log. Eight children were not properly signed into the facility by their authorized representative (See LIC809D). All staff have obtained a criminal record clearance. LPA obtained the facilities files, children’s files and staff files. All files were complete.
Continued on LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 013412608
VISIT DATE: 10/17/2022
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Deficiencies cited during inspection
· Eight children not properly signed in

Director was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Personnel Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. Director was reminded that California Law requires all facilities 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 email. LPA informed Director that all forms can be downloaded at www.ccld.ca.gov. Director was also informed 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.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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.

Continued on LIC809-C

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

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 013412608
VISIT DATE: 10/17/2022
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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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

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

Exit interview conducted and report was reviewed with Director Jamie Czelusniak.

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

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2022 03:57 PM - It Cannot Be Edited


Created By: Morgan Pringle On 10/17/2022 at 02:48 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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 013412608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

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 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2022
Plan of Correction
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Director will ensure that all eight children are properly signed for 10/17/2022 and thereafter. Licensee will send LPA Pringle a copy of off children's sign in/out sheet with the children properly signed in for 10/17/2022. Director will submit a statement to LPA on how the facility will ensure all children are properly signed in at all times.
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:Jason Jang
LICENSING EVALUATOR NAME:Morgan Pringle
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2022


LIC809 (FAS) - (06/04)
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