<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419067
Report Date: 11/29/2023
Date Signed: 11/29/2023 11:04:14 AM

Document Has Been Signed on 11/29/2023 11:04 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:ZIKA, MARJORIEFACILITY NUMBER:
013419067
ADMINISTRATOR:ZIKA, MARJORIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 371-5621
CITY:LIVERMORESTATE: CAZIP CODE:
94551
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
11/29/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Marjorie ZikaTIME COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On November 29, 2023, Licensing Program Analyst (LPA) Simerjit Kaur arrived at the facility to conduct UNANNOUNCED RANDOM REQUIRED SITE INSPECTION. LPA met with licensee Marjorie Zika. Upon initial arrival there were 2 preschool age children and 2 infant age children. Present during the inspection 2 children arrived. Present during the inspection was licensee's fingerprint cleared husband George Zika IV. Also residing in the home is licensee’s son George Albert Zika V. Hours of operation for child care are Monday through Friday, 7:00am to 5:30pm. The facility is a two story house. The following was observed during today’s inspection:

CAPACITY: The facility operates as a Family Child Care Home (large), which may have a maximum capacity of twelve (12) to fourteen (14) children. At time of inspection, there were six children (two infants and four preschoolers), and husband/assistant George Zika. The facility is in compliance with ratio and capacity limitations.


ON LIMIT AREAS (accessible to children in care): day care room, second day care room with a kitchen, bathroom, and fenced backyard for children to play. LPA observed the facility to be clean and in good repair, with heating and ventilation for safety and comfort. There are ample age appropriate toys that are observed to be safe and in good condition. The backyard has a fence surrounding the perimeter of the yard. LPA did not observe any dangerous conditions in the ON Limit areas of the facility today.

OFF LIMIT AREAS (not accessible to children in care): family room, kitchen, dining area, garage and entire second floor, which is separated by a locked door. OFF Limit areas are inaccessible by closed and/or locked doors and visual supervision. There is a gated pool on the premises on the off limit side of the backyard. It was observed that there are no toxins or hazardous items accessible today. Licensee is advised to contact Licensing Department, so that an inspection can be completed prior to changing an OFF Limit area to ON Limit. Licensee was reminded that any structural changes or additions to the home must be reported to Community Care Licensing.
Continued on LIC 809C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Simerjit Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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: ZIKA, MARJORIE
FACILITY NUMBER: 013419067
VISIT DATE: 11/29/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
EMERGENCY PREPAREDNESS/SAFETY: Facility has a fully charged 2A10BC fire extinguisher. Smoke and carbon monoxide detectors were tested and found to be functioning. A fire/disaster drill was last conducted on 7/17/2023 and meets the six month requirement. Facility has working telephone service. Per licensee, there are no firearms in the home. Per licensee the Emergency Disaster Plan is current.
STAFF/CHILDREN RECORDS REVIEW: Licensee and all adults living and/or working in the home have proper criminal background clearances. Licensee and George Zika has current CPR/First Aid training, which expires on 6/25/2024. Licensee’s mandated reporter training completed on 8/27/2022. George Zika's Mandated Reporter Training is completed on 12/3/2022. Licensee is in compliance with immunization law. A facility roster is maintained and a copy obtained. All files were complete.
LICENSING POSTING (required): All REQUIRED forms are posted: Facility license, Notification of Parents’ Rights, Earthquake Preparedness, Emergency Disaster Plan. Licensee was reminded that exersaucers, baby walkers, bouncers, jumpers, and similar items are not allowed and that smoking is prohibited in the home during day care hours.

Licensee was reminded that California law requires Licensees to report unusual incidents and/or injuries to children in care, to the child's parents, and to the Department within 24 hours by phone. Within seven (7) days from the incident, Licensee’s must submit the Unusual Incident/Injury form (LIC 624B) to the Department.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
Continue on 809C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: ZIKA, MARJORIE
FACILITY NUMBER: 013419067
VISIT DATE: 11/29/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.
During the exit interview, Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Licensee Marjorie Zika.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/29/2023 11:04 AM - It Cannot Be Edited


Created By: Simerjit Kaur On 11/29/2023 at 10:18 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: ZIKA, MARJORIE
FACILITY NUMBER: 013419067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)(4)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (4) Mattresses shall be made specifically for the size crib or play yard in which they are placed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above as play yard mattress does not fit specifically the size of play yard, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
1
2
3
4
Licensee shall have have correct mattress size for the play yard and send pictures to LPA.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Jason Jang
LICENSING EVALUATOR NAME:Simerjit Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5