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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419452
Report Date: 10/28/2021
Date Signed: 10/28/2021 05:17:51 PM

Document Has Been Signed on 10/28/2021 05:17 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:PALM ACADEMYFACILITY NUMBER:
013419452
ADMINISTRATOR:YEN NGUYENFACILITY TYPE:
850
ADDRESS:2856 WASHINGTON BLVD.TELEPHONE:
(510) 979-9794
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 59TOTAL ENROLLED CHILDREN: 25CENSUS: 22DATE:
10/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Weiling Ko and Chantel BlasTIME COMPLETED:
05:29 PM
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On 10/28/2021, Licensing Program Analysts (LPAs) Jonathan Williams and Melanie Otsuji arrived at the facility unannounced for the purposes of conducting a Required 1-Year Inspection. LPA was met by Weiling Ko, an administrative assistant. Director, Chantel Blas, returned to the facility from an off-site field trip at approximately 12:00pm. Present for this inspection are four staff members (Director, two fully qualified teachers, and one aide) and 22 preschool-aged children in care. Facility operating hours are 8am-6pm M-F. The facility was toured to conduct a health and safety inspection.

LPAs toured the facility classrooms. The facility consists of three classrooms. The classrooms are tidy and clean with heating and ventilation for safety and comfort. There are safe age-appropriate toys and learning materials available to children throughout the classrooms. All hazardous materials and toxins including disinfectants and cleaning solutions were observed to be made inaccessible to children during today's inspection. Furniture accessible to children was observed to be age-appropriate, in operable condition, and free of loose, sharp, or pointed parts. LPAs observed adequate amounts of paper towels and hand soap available to children in the bathrooms during today's inspection.

At 3:41pm, LPAs reviewed sign in/sign out sheets. LPAs observed 22 signatures out of 22 children present in the facility during today's inspection.

At 4:10pm, LPAs toured the outdoor play area. Play equipment was observed to be safe, age-appropriate, and in operable condition at the time of this inspection. Cushioning material is present in sufficient quantities to absorb falls at the time of this inspection. Outdoor play area is fenced and has a shaded area. There are no pools, hot tubs, ponds, or any other bodies of water accessible to children during today's inspection. Uncontaminated drinking water is present in the outdoor play area for children to drink upon request.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: PALM ACADEMY
FACILITY NUMBER: 013419452
VISIT DATE: 10/28/2021
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The facility has multiple fully charged 4A80BC fire extinguishers and working telephone. Smoke detectors are connected to the fire department, and per staff, are serviced regularly. At least one staff member has current CPR/1st Aid certificate. The facility is in ratio today. Children's files and staff files were reviewed for proper documentation. All required forms are posted in public view, including menus. Facility roster was obtained.

Incidental Medical Services (IMS) policy was discussed. This facility does not provide IMS to children in care at this time. 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: http://www.ada.gov/childqanda.htm.”

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Director was reminded that California Law requires licensed Child Care Centers to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the Director that all forms can be downloaded at www.ccld.ca.gov and encouraged the Director to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The Director was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

There are no deficiencies cited. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director. Appeal rights were provided to the Director and the signature on this form acknowledges receipt of these rights.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC809 (FAS) - (06/04)
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