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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420914
Report Date: 04/18/2024
Date Signed: 04/18/2024 02:50:20 PM

Document Has Been Signed on 04/18/2024 02:50 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/
DIRECTOR:		SIGMAN, CHARLENEFACILITY TYPE:
850
ADDRESS:9801 DUBLIN BLVDTELEPHONE:
(925) 829-9552
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 87TOTAL ENROLLED CHILDREN: 87CENSUS: 71DATE:
04/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Director, Charlene Signam TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On 4/18/2024, Licensing Program Analyst (LPA) Jyoti Saini arrived at the facility unannounced for the purpose of conducting a Case Management visit in response to an unusual incident reported by the facility Director on 03/28/2024. Present during the inspection, the director, Charlene Sigman, Curriculum Coordinator Lupe, Hernandez, and 25 staff members were supervising 71 children.

In the unusual incident report ( UIR), the facility stated that on 03/27/2024, between 10:30 a.m. and 11:00 a.m.,S1 withheld food from C1. S1 tried to get C1 to sign " Open" to communicate. When C1 could not do it, S1 did not provide access to the food. LPA obtained the written statements of the staff who witnessed this incident. Per facility director, the staff in question (S1) has been suspended effective 03/28/2024.

Director is advised that CCR 101223(a)(3) states that daycare children must be accorded the following personal rights:

"To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning."

Type B deficiency is cited pursuant to CCR 101223(a)(3).
Appeal rights were provided.
A notice of site visit was posted and must remain posted for a period of 30 days.
An exit interview was conducted with Director Charlene Sigman and Curriculum Coordinator Lupe Hernandez.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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 04/18/2024 02:50 PM - It Cannot Be Edited


Created By: Jyoti Saini On 04/18/2024 at 02:15 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: SCHOOL OF IMAGINATION
FACILITY NUMBER: 013420914

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2024
Section Cited
CCR
101223(a)(3)

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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: ...... aids to physical functioning.
This requirement is not met as evidenced by:
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The director and staff shall watch the Personal Rights Video on the CCLD website and formulate a plan to ensure children's safety. Each staff member shall submit a written statement of their understanding of children's personal rights by due date 04/26/2024.
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Based on observations, interviews, and record reviews, the facility did not comply with the section cited above. S1 withheld food from the C1, resulting in a violation of his/her personal rights, which poses a potential risk to the health, safety, and personal rights of the children in care.
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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:Wynn Norona
LICENSING EVALUATOR NAME:Jyoti Saini
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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