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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013412740
Report Date: 12/08/2021
Date Signed: 12/08/2021 11:48:14 AM

Document Has Been Signed on 12/08/2021 11:48 AM - 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:DIVERSITY CHILDREN'S CENTERFACILITY NUMBER:
013412740
ADMINISTRATOR:DO, BICHNGANFACILITY TYPE:
850
ADDRESS:37371 FILBERT STREETTELEPHONE:
(510) 797-7190
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 56TOTAL ENROLLED CHILDREN: 14CENSUS: 14DATE:
12/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bichngan DoTIME COMPLETED:
12:07 PM
NARRATIVE
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On 12/08/2021, Licensing Program Analyst (LPA) Jonathan Williams arrived at the facility unannounced for an unrelated matter. LPA was met by Director, Bichngan Do. Present for today's visit were Director, one fingerprint cleared and associated staff member, and 14 preschool-aged children in care.

Based on statement made by Director, an incident occurred at the facility on or around July 2021 during which a child fell while using a scooter and injured his head on the handlebars. Director stated that the child required medical attention as a result of the injury. Director stated that the incident was reported to parents but not reported to Community Care Licensing. Type B citation is hereby assessed pursuant to CCR 101212(d)(1)(B).

Director is advised that all injuries to children requiring medical attention must be reported to the Department.

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 (510-622-2602), fax, or electronic mail and LIC624 must be submitted to CCLD regional office within 7 days

Copies of applicable regulations (CCR 101212) provided to Director. Copy of LIC624 provided to Director. Plan of Correction discussed at length and Q&A provided.

Exit interview conducted. Appeal Rights provided.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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 12/08/2021 11:48 AM - It Cannot Be Edited


Created By: Jonathan Williams On 12/08/2021 at 11:06 AM
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: DIVERSITY CHILDREN'S CENTER
FACILITY NUMBER: 013412740

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/08/2022
Section Cited
CCR
101212(d)(1)(B)

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101212(d)(1)(B) Events reported shall include the following: (B) Any injury to any child that requires medical treatment.

This requirement was not met as evidenced by:
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Director shall submit a written plan detailing how facility staff will properly report unusual incidents to the Department. Plan shall demostrate knoweldge of what kinds of incidents meet reporting requirements and what the applicable deadlines are.
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Based on Director statement, a child sustained an injury at the facility that required medical attention. No report was made to the Department. This poses a potential risk to the health and safety to children in care.
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Failure to correct will result in civil penalty assessed of $250.

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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:Jonathan Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2021


LIC809 (FAS) - (06/04)
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