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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419494
Report Date: 10/28/2021
Date Signed: 10/28/2021 05:15:03 PM

Document Has Been Signed on 10/28/2021 05:15 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:
013419494
ADMINISTRATOR:YEN NGUYENFACILITY TYPE:
840
ADDRESS:2856 WASHINGTON BLVDTELEPHONE:
(510) 979-9794
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 72TOTAL ENROLLED CHILDREN: 29CENSUS: 28DATE:
10/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Chantel BlasTIME COMPLETED:
05:29 PM
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 10/28/2021, LPAs Jonathan Williams and Melanie Otsuji arrived at the facility for an unrelated matter and observed a regulatory violation. Present for this inspection are five staff members (Director, five teachers) and 28 school-aged children in care.

During today's visit at 12:49pm, LPAs Williams and Otsuji observed a school-aged child to exit the bathroom and attempt to open a door leading into a classroom. LPAs observed the child to be unattended. LPA Otsuji alerted facility Director of the unattended child, and Director immediately let the child into the classroom.

Type A deficiency is assessed pursuant to CCR 101229(a)(1):
_________________________________________________________________________
101229 Responsibility for Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the children's needs.
(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
_________________________________________________________________________

Licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility. Licensee shall provide copies of LIC9224 to parents/guardians of children in care and maintain signed copies in the files for each child enrolled at the facility. Both shall be completed for each newly enrolled child at the facility for a period of 12 months from today's date.

Appeal Rights and Notice of Site Visit provided. Exit interview conducted.
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)
Page: 1 of 2
Document Has Been Signed on 10/28/2021 05:15 PM - It Cannot Be Edited


Created By: Jonathan Williams On 10/28/2021 at 01:27 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: PALM ACADEMY
FACILITY NUMBER: 013419494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2021
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).
1
2
3
4
5
6
7
Facility staff shall attend trainings on proper supervision. Director shall submit training materials to LPA within 24 hours via email or civil penalty will be assessed.
8
9
10
11
12
13
14
This requirement was not met as evidenced by: Based on LPA observations, a child was left unattended for a period of several minutes. This poses an immediate risk to the health and safety of children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Wynn Norona
LICENSING EVALUATOR NAME:Jonathan Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2