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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422003
Report Date: 03/22/2024
Date Signed: 03/22/2024 10:57:07 AM

Document Has Been Signed on 03/22/2024 10:57 AM - 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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:OUSD - UNITED NATION CHILD DEVELOPMENT CENTERFACILITY NUMBER:
013422003
ADMINISTRATOR:MANSKER, ANNAFACILITY TYPE:
850
ADDRESS:1025 - 4TH AVETELEPHONE:
(510) 273-1616
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 168TOTAL ENROLLED CHILDREN: 136CENSUS: 112DATE:
03/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jacquetta WallaceTIME COMPLETED:
11:15 AM
NARRATIVE
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On 03/22/2024 at 8:45 AM Licensing Program Analyst (LPA) A. Curry conducted an unannounced case management inspection to follow up on a self-reported unusual incident where a child was left without supervision. LPA met with the Lead Teacher, Jacquetta Wallace, to explain the purpose of today's visit. LPA toured the facility and conducted interviews with staff. The interviews revealed that C1 eloped from the playground and was found outside the front door of the facility waiting to be let back in (See 809D). Staff were unsure of how long C1 was outside of the facility unsupervised. The staff indicated C1 has eloped from the playground several times and was left without supervision of a staff. Licensing was not notified of the several incidents where C1 was left unsupervised (See 809D) The facility was advised to report all unusual incidents within the next business day and submit the Unusual Incident Report form within 7 days of the incident occurring.

Exit interview conducted, appeal rights were given, and report reviewed with Lead Teacher, Jacquetta Wallace.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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 03/22/2024 10:57 AM - It Cannot Be Edited


Created By: Ashley Curry On 03/22/2024 at 10:30 AM
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: OUSD - UNITED NATION CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 013422003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2024
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision. (a)The licensee shall provide care and supervision as necessary to meet the children's needs.(1) No child(ren) shall be left without the supervision of a teacher at any time..
This requirement is not met as evidence by:
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By 03/25/2024 email LPA a written plan how they will ensure C1 does not elope from the playground anymore.

By 04/22/2024 conduct an all staff training on supervision. Email LPA the Agenda and attendance sheet for training.
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Based on interviews the licensee did not comply with the section cited above by ensuring no child is left without supervision of a teacher at any time. Interviews revealed C1 was left without supervision on multiple occassions, which poses an immediate risk to the health and safety of 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:Mayla Mendoza
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/22/2024 10:57 AM - It Cannot Be Edited


Created By: Ashley Curry On 03/22/2024 at 10:37 AM
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: OUSD - UNITED NATION CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 013422003

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2024
Section Cited
CCR
101212(d)

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101212Reporting Requirements(d)..any of the events specified in (d)(1), a report shall be made.. by telephone or fax within the Department's next working day...a written report.. shall be submitted to the Department within seven days following the occurrence of such event.
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By 04/12/2024 email LPA a written statement on how the facility will comply with the Reporting Requirements regulations.
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Based on interviews the licensee did not comply with the section cited above by not reporting all the incidents where a child was left without supervision, which poses a potential risk to the health, safety, and personal rights of 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:Mayla Mendoza
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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