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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013414320
Report Date: 08/03/2023
Date Signed: 08/03/2023 01:06:49 PM

Document Has Been Signed on 08/03/2023 01:06 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 EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:AGNEW, DOROTHY & STEPHENS, CLEOTHAFACILITY NUMBER:
013414320
ADMINISTRATOR:AGNEW, DOROTHYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 614-9156
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
08/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Abeer Nasser - TeacherTIME COMPLETED:
01:00 PM
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 Licensing Program Analysts (LPAs) Andrew Elliot met with Assistant Teacher Abeer Nasser for an unannounced Annual Random Inspection on August 3rd, 2023 at 10:00 am. LPA disclosed the purpose of the inspection and was granted entry into the facility by the staff at 10:15 am. 2 Staff members, a 3rd party behavioral technician, 2 infants, 6 pre-school aged children, and 2 school aged children were present at the beginning of the inspection. Licensee Dorothy Agnew arrived later during the inspection at approximately 11:00 am. Licensee lives in the house alone. All adults requiring background clearance have been cleared and associated to this facility. The hours of operation are 7:00AM- 5:30PM, Monday-Friday.
ON LIMITS: The large playroom located near the back of the home, and converted driveway adjacent to the day care area, short hallway through living room and bathroom.
OFF LIMITS: The master bedroom and garage.
LPA inspected the house for health and safety hazards. Daycare Area is clean, orderly, and equipped with age-appropriate toys and equipment for children, indoors and outdoors. Home has a
working telephone, a working smoke and carbon monoxide detector, and a fully charged model 3A40BC fire extinguisher that meets the minimum requirements.

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SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Andrew Elliott
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: AGNEW, DOROTHY & STEPHENS, CLEOTHA
FACILITY NUMBER: 013414320
VISIT DATE: 08/03/2023
NARRATIVE
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 There are ample of age-appropriate toys that appear to be safe and in good condition. The fully fenced back play area is available for children in care. The Licensee has a trampoline in the backyard. LPA advised her that she must comply with the manufacturer instructions listed on the trampoline, including supervision requirements, if any of the day care children use the trampoline. LPA observed that an above ground hot tub is present in the backyard. The above ground hot tub is made inaccessible to children by an enclosure and a tightly fitted covering. LPA observed that several hazardous materials and toxins were placed on a low cabinet in the bathroom and were accessible to children during today’s inspection. Licensee explained that the cabinet had been secured with a child proof lock, but the lock had broken, and she had been unable to have it repaired due to her husband’s injury. LPA directed the Licensee to immediately relocate the toxic substances to a high self out of reach of children. The licensee complied with LPA direction. LPA observed that the last recorded fire drill and earthquake drill occurred in January of 2023. LPA communicated to the licensee that fire drills and earthquake drills must be performed and documented at least every six months. LPA directed the licensee to perform and document both an earthquake drill and a fire drill during the random annual inspection and document that the drills were performed. Licensee complied with LPA’s direction and LPA observed that children and staff were able to evacuate the facility in a safe and timely manner. Licensee provides daily snacks and lunch. Discipline policy is redirection. LPA reviewed children’s files. All the files are complete and up to date. All required postings are properly posted.

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SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Andrew Elliott
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: AGNEW, DOROTHY & STEPHENS, CLEOTHA
FACILITY NUMBER: 013414320
VISIT DATE: 08/03/2023
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 To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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.

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SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Andrew Elliott
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: AGNEW, DOROTHY & STEPHENS, CLEOTHA
FACILITY NUMBER: 013414320
VISIT DATE: 08/03/2023
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 Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

Exit interview conducted and report was reviewed with the licensee Dorothy Agnew.

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SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Andrew Elliott
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC809 (FAS) - (06/04)
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