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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420528
Report Date: 04/19/2021
Date Signed: 04/19/2021 04:58:49 PM

Document Has Been Signed on 04/19/2021 04:58 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:DR. HERBERT GUICE CHRISTIAN ACADEMYFACILITY NUMBER:
013420528
ADMINISTRATOR:LARHONDA D. MARTINFACILITY TYPE:
850
ADDRESS:6925 INTERNATIONAL BLVDTELEPHONE:
(510) 729-0330
CITY:OAKLANDSTATE: CAZIP CODE:
94621
CAPACITY: 57TOTAL ENROLLED CHILDREN: 0CENSUS: 15DATE:
04/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:58 PM
MET WITH:Karen FreemanTIME COMPLETED:
05:15 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 04/19/2021 LPA's Cherie Acosta and Diana Campos conducted a case management inspection. During the course of a complaint investigation LPA's observed 1 teacher supervising 15 children. At approximately 3:30pm 12 children were awake and 3 were napping with only 1 teacher in the classroom.

The attached type A violation is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC 9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.

Exit interview conducted with Ms. Freeman and a notice of site visit posted. Appeals rights provided.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2021
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 04/19/2021 04:58 PM - It Cannot Be Edited


Created By: Diana Campos On 04/19/2021 at 04:14 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: DR. HERBERT GUICE CHRISTIAN ACADEMY
FACILITY NUMBER: 013420528

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/20/2021
Section Cited
CCR
101216.3

1
2
3
4
5
6
7
There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below. This was not met as evidenced by:
1
2
3
4
5
6
7
Director shall submit a plan of correction by end of 04/20/2021
8
9
10
11
12
13
14
LPA's observed one teacher supervising 15 children which 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:Sherelle Johnson
LICENSING EVALUATOR NAME:Diana Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2021


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