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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419452
Report Date: 11/18/2021
Date Signed: 11/18/2021 01:28:35 PM

Document Has Been Signed on 11/18/2021 01:28 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
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: 26CENSUS: 21DATE:
11/18/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Chantel BlasTIME COMPLETED:
01:47 PM
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A Case Management Inspection was conducted on this date 11/18/2021 by Licensing Program Analyst (LPA), Melanie Otsuji. LPA met with Director, Chantel Blas. Currently the preschool program uses rooms 1, 2, 3, and 5. Room 1 and 5 are currently being shared with the school age program when school age children are not present. The center has applied for a Toddler Option Component. The preschool program capacity will remain at 59 which will include the option to have 12 toddlers (ages 18 months - 36 months) in classroom 2. Facility has also requested to add a toddler playground to the licensed space A health and safety inspection was conducted inside and outside. Hours of operation are from 7:00am-7:00pm, Monday through Friday. The preschool measurements are as follows:

INDOORS: 2791.78 square feet = 79 children
OUTDOORS: 8988.05 square feet = 119 children

First aid supplies are available in the center. Facility has a functioning carbon monoxide detector. Mandated reporter and appeal rights, civil penalties, unusual incident reporting and fingerprint requirements were discussed today. Licensee is also being informed of the web address (www.ccld.ca.gov) for downloading child care forms, and the director is encouraged to email ChildCareAdvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The director is also reminded that mandated reporter training is required for all staff and is to be renewed every 2 years at www.mandatedreporterca.com.

There were no deficiencies cited during this visit. When either Room 1 or 5 are being utilized by School Age children, preschool capacity must be reduced to 49 children. Approval of the toddler option component which will allow up to 12 toddlers (ages 18 months - 36 months) of age to operate in Room 2 is approved on today's date, 11/18/2021. Total overall capacity for Preschool component including toddlers is 59. Also on site are 12 infants and 72 school aged children. Exit interview conducted.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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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