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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417305
Report Date: 10/03/2022
Date Signed: 10/03/2022 03:51:40 PM

Document Has Been Signed on 10/03/2022 03:51 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:S.S.U.C. - DE COLORES HEADSTART & EARLY HEADSTARTFACILITY NUMBER:
013417305
ADMINISTRATOR:MICHELLE FREEMANFACILITY TYPE:
850
ADDRESS:1155 - 35TH AVENUETELEPHONE:
(510) 535-6106
CITY:OAKLANDSTATE: CAZIP CODE:
94601
CAPACITY: 134TOTAL ENROLLED CHILDREN: 134CENSUS: DATE:
10/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ana Baptista TIME COMPLETED:
03:55 PM
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On 10/3/22 at 2:00 PM Licensing Program Analyst (LPA) Michelle Sutton conducted an unannounced Case Management inspection about an unusual incident self reported by the Center about two child left unattended walking to the playground. LPA met with Center Director Ana Baptista and explained the purpose of today's inspection.

LPA conducted staff interviews during today's inspection. Copies of The Children's Roster, Personnel Report LIC500 and incident written statements were obtained. LPA was able to tour the premises with the center director and observe how far away the classroom and playground are. During the inspection, it was determined that Child 1 and Child 2 left their classroom on the first level unattended and walked up to the second level to the play yard. Facility is being cited Type A for lack of supervision.

Due to the issuance of Type A, this report has to be provided to all parents of currently and future enrolled over next 12 months. Report and deficiency page also to be posted in public view. A copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports to be signed by parent and kept in child file.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Center Director Ana Baptista.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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 10/03/2022 03:51 PM - It Cannot Be Edited


Created By: Michelle Sutton On 10/03/2022 at 03:24 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: S.S.U.C. - DE COLORES HEADSTART & EARLY HEADSTART
FACILITY NUMBER: 013417305

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2022
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care & Supervision (a) [..] provide care and supervision [..]meet the children's needs (1) No child(ren) shall be left without the supervision [..] include visual observation. This requirement is not met as evidenced by:
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By POC Facility will submit a written plan of action on how facility will ensure full supervision at all times and understanding Licensing Regulation for Providing Care and Supervison.
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Based on observation, record review and interviews Child 1 and Child 2 were left unattended leaving the classroom and walking to the playground on the second level, which poses an immediate health, safety or personal rights risk to persons in care.
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By 10/10/22 All staff meeting/training will be held and a video on Supervision on CCLD website will be reviewed by all. Site Supervisor will submit proof of staff meeting

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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Michelle Sutton
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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