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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013416337
Report Date: 07/25/2024
Date Signed: 07/25/2024 02:44:43 PM

Document Has Been Signed on 07/25/2024 02:44 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:PIERCE, FORRESTINEFACILITY NUMBER:
013416337
ADMINISTRATOR/
DIRECTOR:		PIERCE, FORRESTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 581-1109
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
07/25/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jharana Bhujel- AssistantTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 7/25/24, Licensing Program Analyst Briana Plumboy, met with assistant Jharana Bhujel for an UNANNOUNCED REQUIRED 1 YEAR ANNUAL INSPECTION. Present for this visit was 2 infants, 7 preschool age children, a teenage assistant, and fingerprint clear and associated assistant Jharana Bhujel. The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday through Friday from 6:30am until 5:30pm.

The home is a two story home. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the living room, the kitchen, the dining room, the downstairs den, and the downstairs bathroom. The OFF LIMIT AREAS are the bedroom on the left located next to the bathroom, the upstairs hallway bathroom, first bedroom on the right, the first bedroom on the left, and the garage which will be inaccessible by closed and/or locked doors and visual supervision. The upstairs on limit areas are designed for infants, and the on limit areas located inside the lower level of the home are designed for toddlers. There is a door located inside the kitchen area which leads to the downstairs toddler area, as well as a gate located at the top of the stairs and a gate located at the bottom of the stairs. The ISOLATION AREA will be the dining room area located in the kitchen. The BACKYARD play area is fenced. There are toys, learning materials, and play equipment. There are no pools, hot tubs or any other bodies of water present in the on limit areas during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible during today's inspection.
The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The fireplace is screened and also has a barricade to prevent access by children. All REQUIRED forms are posted and visible for public review. See 809-C for continuance
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: PIERCE, FORRESTINE
FACILITY NUMBER: 013416337
VISIT DATE: 07/25/2024
NARRATIVE
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LPA Plumboy will return to conduct a follow up annual inspection/ annual continuation inspection.

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

See 809-D for deficiency cited during today's inspection. Appeal rights provided and discussed. Exit interview conducted and report was reviewed with assistant Jharana Bhujel.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
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Document Has Been Signed on 07/25/2024 02:44 PM - It Cannot Be Edited


Created By: Briana Plumboy On 07/25/2024 at 02:19 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: PIERCE, FORRESTINE
FACILITY NUMBER: 013416337

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

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 due to her assistant's CPR/ First Aid certificate not being EMSA approved or in compliance with the regulation, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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The Licensee will submit proof of enrollment in an approved CPR/First Aid course to LPA for her assistant by email, fax, text or or mail by 8/5/24, and complete the course by 8/16/24. Once the course is completed, licensee will submit a copy of her CPR/First Aid card to LPA Plumboy.
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:Wynn Norona
LICENSING EVALUATOR NAME:Briana Plumboy
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


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