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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417033
Report Date: 10/23/2024
Date Signed: 10/23/2024 03:28:27 PM

Document Has Been Signed on 10/23/2024 03:28 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 CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:FREMONT PARENTS NURSERY SCHOOLFACILITY NUMBER:
013417033
ADMINISTRATOR/
DIRECTOR:		MILLER, JESSICAFACILITY TYPE:
850
ADDRESS:4200 ALDER AVENUETELEPHONE:
(510) 793-8531
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 4DATE:
10/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:17 PM
MET WITH:Stacy GohmanTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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On October 23, 2024 Licensing Program Analyst (LPA) Randy Miranda met with Director Stacy Gohman, for the purpose of an Unannounced Case Management Visit. The facility self reported on 10/08/2024 and a copy of the Unusual Incident Report (UIR) was reviewed by LPA. Per the report, Child 1 (C1) was found by his parents, unsupervised in the building for at least one minute. As a result, there was Lack of Supervision - one child was left inside the classroom without supervision. Although the facility states that the child was left inside alone for one minute, Title 22 Regulations 101229 (a)(1) states that no children shall be left without the supervision of a teacher at any time including visual supervision.

The facility will be cited a Type A citation. Please see LIC 809D.

The facility must post this report for thirty days. The facility must give each parent of the children in care and future parents of newly enrolled children, for the next twelve(12) months, a copy of this report. Parents are to sign an LIC 9224 – Acknowledgement of Receipt of Licensing Reports and this form shall be placed in each child’s file. Failure to post report and or provide a copy of this report to parent’s/authorized guardians can result in additional monetary assessments to the facility.

This report must remain on file for three years.

Notice of site visit was provided and must be posted for 30 days. Appeal Rights provided.

Exit interview conducted and reviewed with Director Stacy Gohman.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Randy Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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 10/23/2024 03:28 PM - It Cannot Be Edited


Created By: Randy Miranda On 10/23/2024 at 02:43 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: FREMONT PARENTS NURSERY SCHOOL
FACILITY NUMBER: 013417033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
CCR
101229(a)(1)

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(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.

This requirement is not met as evidenced by:
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The facility will submit a Plan of Correction in writing by indicating how they will ensure that children are always directly supervised. Staff will also watch a video on Supervision on CCLD website. A copy of the summary of the training and a roster of staff who attended the training will be sent to LPA by two weeks.
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Based on self reported Unusual Incident Report, interview, and record review the facility did not ensure children were accounted for during 1 minute, which poses an immediate risk to the health and safety of children in care.
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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:Randy Miranda
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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