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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420528
Report Date: 06/24/2021
Date Signed: 06/24/2021 03:06:43 PM

Document Has Been Signed on 06/24/2021 03:06 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:ANGELA DARBYFACILITY TYPE:
850
ADDRESS:6925 INTERNATIONAL BLVDTELEPHONE:
(510) 729-0330
CITY:OAKLANDSTATE: CAZIP CODE:
94621
CAPACITY: 57TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
06/24/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Angela DarbyTIME COMPLETED:
03:20 PM
NARRATIVE
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On 6/24/2021 Licensing Program Analysts (LPA's) Cherie Acosta and Diana Campos met with Center Director Angela Darby for a case management inspection as a result of an incident that was reported to licensing. An incident occurred when the parents of a child in care reported in person to the facility acting director that on Friday 4/16/21 their child fractured their arm while in care. Following the incident a staff member called licensing to report that the parent indicated that child was injured while in care. However, acting Director failed to submit a written unusual incident report. During todays inspection, LPA's conducted staff interviews. Staff stated that the child was not injured while in care. Per staff interviews on Friday 4/16/21 when the child left, he was not showing any signs of injury. Staff did not witness any incidents. LPA's are not able to determine at this time if the injury happened while child was in care at the facility.

The attached type B deficiency is cited today and must be corrected by the due date.

An exit interview was conducted and the report was discussed. Licensee was provided a copy of their appeal rights and the signature on this form acknowledges receipt of these rights.

A site visit notice was posted by Staff.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2021
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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Document Has Been Signed on 06/24/2021 03:06 PM - It Cannot Be Edited


Created By: Diana Campos On 06/24/2021 at 02:34 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: 06/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2021
Section Cited
CCR
101212(d)

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Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department... In addition, a written report containing the information
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Director shall submit an unusual incident report. Director shall review the regulation and submit a statement indicating she understands the reporting requirements.
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 specified in (d)(2) below shall be submitted to the Department within seven days...
This requirement was not met as evidenced by:
Director failed to submit unusual incident report.
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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.
SUPERVISOR'S NAME:Sherelle Johnson
LICENSING EVALUATOR NAME:Diana Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2021


LIC809 (FAS) - (06/04)
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