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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013415387
Report Date: 02/09/2023
Date Signed: 02/09/2023 11:46:17 AM

Document Has Been Signed on 02/09/2023 11:46 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:OAKLAND HEAD START - 85TH AVENUE CENTERFACILITY NUMBER:
013415387
ADMINISTRATOR:COOPER, ARNETTAFACILITY TYPE:
850
ADDRESS:8501 INTERNATIONAL BOULEVARDTELEPHONE:
(510) 544-3821
CITY:OAKLANDSTATE: CAZIP CODE:
94621
CAPACITY: 28TOTAL ENROLLED CHILDREN: 28CENSUS: 13DATE:
02/09/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lynn PhamTIME COMPLETED:
11:58 AM
NARRATIVE
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LPA Lisa Dyer met with Director Lynn Pham for a Case Management Visit as a result of receiving an unusual incident report.

Staff were transitioning children from the playground to inside the facility. Staff failed to notice that a child was missing from the group. Children went to the restroom and were in line, waiting to wash their hands. A count was taken and it was noticed that one child was missing. Staff member checked the classroom and the child was not there. Staff member was on her way to the playground and the janitor walked up to her and told her a child was outside. The staff member went out and brought the child back into the facility.

Per the director, a staff meeting took place and additional training was completed.

The attached type A violation is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.

An exit interview was conducted and the report was discussed. Licensee was provided a copy of their Appeal Rights. Notice of site visit was posted.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Phyllis Dyer
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2023
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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Document Has Been Signed on 02/09/2023 11:46 AM - It Cannot Be Edited


Created By: Phyllis Dyer On 02/09/2023 at 10:41 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: OAKLAND HEAD START - 85TH AVENUE CENTER
FACILITY NUMBER: 013415387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/10/2023
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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By 2/11/23, director will provide a written plan of action. This plan will be e-mailed, mailed or faxed to Licensing. Director will detail the steps that staff will complete to insure that children are visually supervised at all times.
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This requirement was not met as evidenced by report review and interviews conducted. Child was left alone on the playground without supervision. This poses an immediate risk to the Health and Safety of children 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:Loretta Dyson
LICENSING EVALUATOR NAME:Phyllis Dyer
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023


LIC809 (FAS) - (06/04)
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