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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420914
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:00:34 PM

Document Has Been Signed on 09/14/2023 03:00 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SCHOOL OF IMAGINATIONFACILITY NUMBER:
013420914
ADMINISTRATOR:SIGMAN, CHARLENEFACILITY TYPE:
850
ADDRESS:9801 DUBLIN BLVDTELEPHONE:
(925) 829-9552
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 87TOTAL ENROLLED CHILDREN: 87CENSUS: 69DATE:
09/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Director, Charlene SigmanTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Saini met with Director, Charlene Sigman for an unannounced case management inspection in response to an Unusual Incident that the Facility self-reported to the Department on July 6th,2023.

LPA Saini conducted interviews with the center director, the teachers of room #7 (where the child was enrolled) and obtained documents.

No deficiencies were cited today.



Exit interview conducted and copy of report provided to the facility representative, Charlene Sigman.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2023
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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