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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013418921
Report Date: 05/06/2021
Date Signed: 05/06/2021 04:17:58 PM

Document Has Been Signed on 05/06/2021 04:17 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:KANBERGS, CHRISTINEFACILITY NUMBER:
013418921
ADMINISTRATOR:KANBERGS, CHRISTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 521-7132
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
05/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:KANBERGS, CHRISTINETIME COMPLETED:
02:20 PM
NARRATIVE
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On May 06, 2021, Licensing Program Analyst (LPA) L. Chew made an unannounced case management inspection.

LPA introduced and displayed identification to staff members.. LPA disclosed purpose for today’s inspection. Licensee was not present during this inspection. LPA met with fingerprint cleared and associated staff member Karen Cabalbag-Fullen.

Census were taken.

Present at the facility 2 additional fingerprint cleared/associated staff members and 6 children in care
(2 infants, 1 school-age and 3 preschool-age).

The facility has a separate single-room cottage area located outside in rear of the backyard.

During the course of the complaint investigation conducted on 5/5/2021, LPA conducted interviews. it was disclosed, on more than one occasion, children in care are allowed inside the off-limit area of the facility, which is located in a staff member cottage area called "Poppa Scott House". It was also disclosed, staff member yells at children in care, as a form of discipline.

An exit interview was conducted. LPA discussed, reviewed the reports and appeal rights with staff member.

Staff member was advised, 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. See 809-D for deficiency being cited, today.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Lakeisha Chew
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2021
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 05/06/2021 04:17 PM - It Cannot Be Edited


Created By: Lakeisha Chew On 05/05/2021 at 03:50 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: KANBERGS, CHRISTINE
FACILITY NUMBER: 013418921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2021
Section Cited
CCR
102423(a)(6)

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102423(a)(4)Personal Rights-(4) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse.
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By 6/4/21 All Staff Training. Submit a Summary of Training and Proof of Completion of Training.


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This requirement was not met as evidenced by interviews conducted. It was determined that a staff member yells at children in care as a form of discipline. This poses a potential risk for the health and safety of children in care.
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Staff members will submit individual written summaries of personal rights video
on CCLD website, regulations and acknowledging their understanding of and an agreement to abide by CCL Regulations.
Type B
05/06/2021
Section Cited
CCR102416.3(a)(4)

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102416.3(a)(6) Alterations to Existing Buildings or Grounds - Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.
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By 6/4/ 2021 Licensee will submit an Affidavit statement to CCL. this agreement of and CCL regulation.
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This requirement was not met as evidenced by interviews conducted. It was determined that
on more than one occasion, children in care are in the off-limit area of facility located in rear of home, staff member cottage area.
This poses a potential risk for the health and safety of children in care.
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Licensee will submit a writtten statement of Licensee understanding of the CCL regulation and explaini how Licensee will abide by this agreement.
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:Lakeisha Chew
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2021


LIC809 (FAS) - (06/04)
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