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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 013420528
Report Date: 05/05/2021
Date Signed: 05/05/2021 05:09:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2021 and conducted by Evaluator Diana Campos
PUBLIC
COMPLAINT CONTROL NUMBER: 02-CC-20210217121236

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:57CENSUS: 13DATE:
05/05/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Karen FreemanTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility staff are not providing adequate supervision to children in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cherie Acosta and Diana Campos conducted an unannounced visit to investigate the above allegation. Present during the investigation was 5 staff and 13 preschoolers in care.

It was alleged that facility staff are not providing adequate supervision to children in care. During the course of the investigation, interviews were conducted, staff files were reviewed. Based on the evidence and interviews conducted it was determined that on at least one occasion a staff member was not providing active supervision to children in care.
Based on the interviews conducted and record review(s), the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter Number
101229(a) are being cited on the attached LIC 9099D.

A SITE VISIT NOTICE WAS POSTED BY LICENSEE.

Exit interview was conducted with Karen Freeman. Appeal rights were provided. Notice of Site Visit was provided and must be posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 02-CC-20210217121236
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 ACADEMY
FACILITY NUMBER: 013420528
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2021
Section Cited
CCR
101229(a)
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Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the children's needs. This requirement was not met as evidenced by:
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Director shall submit a written Plan of Action explaining how adequate supervision will be provided at all times by 5/12/2021.
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on at least one occasion a staff member was not providing active supervision to children in care. This poses a potential risk to the health and safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5