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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013414320
Report Date: 09/25/2025
Date Signed: 09/25/2025 12:49:22 PM

Document Has Been Signed on 09/25/2025 12:49 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/
DIRECTOR:		AGNEW, DOROTHYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 614-9156
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
09/25/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Dorothy AgnewTIME VISIT/
INSPECTION COMPLETED:
01:05 PM
NARRATIVE
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On September 25, 2025, at 10:15 AM, Licensing Program Analyst (LPA) Elimika Woods conducted an unannounced Annual/Random Inspection and met with licensee Dorothy Agnew. LPA disclosed the purpose of the visit and conducted a health and safety inspection, touring the facility both inside and outside. Present during the inspection were four children, two infants and two preschool-age children. Also present during this inspection was the licensee's fingerprint cleared assistant. The facility operates Monday through Friday from 7:30 AM to 5:30 PM.

This single-story home, owned by the licensee, consists of two bedrooms, one and a half bathrooms, a childcare room, kitchen, living room, backyard, and detached garage. The home was observed to be clean, orderly, and equipped with central heating and ventilation for safety and comfort. LPA asked the licensee if she transports children in care. The licensee stated that she does not provide transportation. LPA also asked if there were any firearms in the home, and the licensee stated there were none.

On-limit-areas include: Day care room, backyard, hallway bathroom, bedroom next to day care room, and kitchen.
The Isolation area of the home will be bedroom next to the day care room, away from other children in care.

Off-limit-areas include: two bedrooms near the hall, living room, laundry area and garage.
The off-limits will be made inaccessible by closed and/or locked doors and visual supervision.

At 10:20 AM, LPA inspected the backyard area and confirmed that no pools were present in the on-limit area, in compliance with childcare licensing regulations. The backyard play area is fully fenced and free from defects or dangerous conditions. A fully enclosed/netted trampoline with a secured closure was observed. LPA reminded the licensee that trampoline use requires direct adult supervision at all times when children are present. The detached garage is locked to prevent child access. A hot tub is also located in the backyard. LPA inspected the hot tub and verified that it was safe and secured with locks and/or fasteners, meeting regulatory standards. The play area includes small slides with cushioning underneath to absorb falls, a playhouse, tables, chairs, and age-appropriate play equipment for both infants and preschool-age children.



See 809-C for continuance.
NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/25/2025
NARRATIVE
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LPA inspected the cabinets in the on-limit areas, which include the day care room, hallway bathroom, bedroom next to day care room, kitchen, and did not observe any hazardous materials or toxins accessible to children during today’s inspection. LPA tested the smoke detector and the carbon monoxide detector in hallway and found both to be functioning properly. The home is equipped with a working telephone, a first aid kit, and a fully charged 3A40BC fire extinguisher, which meets the standards established by the State Fire Marshal.

At 11:00 AM, LPA requested and reviewed the files of four (4) children in care and one staff file. All children's files contained Medical Consent, Identification & Emergency Information, and Parent’s Rights forms and the staff file has the required Employee Rights and Statement Acknowledging Requirement To Report Child Abuse forms. During the review, LPA Woods also checked the health records of the licensee, staff, and children and found that the licensee is in compliance with immunization laws applicable to childcare providers.

At approximately 11:20 AM, 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-andresources/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.

The licensee conducts and documents fire and disaster drills once every six months, with the most recent drill conducted on 05/24/2025. The licensee’s Health and Safety training is completed, and their CPR and First Aid certification is current, expiring in 08/2026. Additionally, the licensee completed mandated reporter training on 02/05/2024. The facility roster was reviewed and accurately reflects current children enrolled as well as those no longer attending the facility.

Effective August 1, 2003, California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to children’s parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The licensee was also reminded 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.

See 809-C.
NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
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: 09/25/2025
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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 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.

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.

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

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

The following deficiencies were observed during today's inspection:
At 10:45 AM, LPA observed that S1 did not have a CPR & first aid training certificate in her file.

See 809 D for deficiencies cited today. 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.
NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: Elimika Woods
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2025 12:49 PM - It Cannot Be Edited


Created By: Elimika Woods On 09/25/2025 at 12:23 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: AGNEW, DOROTHY & STEPHENS, CLEOTHA
FACILITY NUMBER: 013414320

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

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 in which S1 did not have their CPR & first aid training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2025
Plan of Correction
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The licensee's assistant (S1) will complete CPR & first aid training and send LPA her certificate by 10/09/25, by fax, email, or text message.
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.
Chandra Charles
NAME OF LICENSING PROGRAM MANAGER:
Elimika Woods
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
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