<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422012
Report Date: 11/13/2023
Date Signed: 11/13/2023 02:13:42 PM

Document Has Been Signed on 11/13/2023 02:13 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 CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:AB'S PRESCHOOL AND DAYCAREFACILITY NUMBER:
013422012
ADMINISTRATOR:BONDS, MISTYFACILITY TYPE:
850
ADDRESS:301 DOWLING BLVDTELEPHONE:
(510) 633-0331
CITY:SAN LEANDROSTATE: CAZIP CODE:
94577
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 6DATE:
11/13/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Faye TomsTIME COMPLETED:
02:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/13/2023 at 9:30AM, Licensing Program Analysts (LPAs) Jaleesa Jackson and Julia Placencia met with Teacher Faye Toms for an Unannounced Required Inspection for AB’s Preschool and DayCare. Present for the inspection were 2 teachers who are both fingerprint cleared and 6 preschool aged children. The program for the preschool children is Monday through Friday from 6:00AM to 6:00PM. The Child Care Center was toured to conduct a Health and Safety Inspection. The facility also operates an infant component #13422032. LPAs observed the preschool component of this child care center.

The preschool operates out of the St Mary Eritrean Orthodox Church. The entrance to the preschool is the left side of the building through the playground. The preschool is currently operating out of one classroom. The classroom has cubbies with children’s names on them. The classroom has chairs and tables equipped for children to use. LPAs observed that the sleeping cots are stored in the preschools office. The isolation area is in the Director’s office. LPAs observed that the carbon monoxide detector in the room was put away in a cabinet not in operational condition with no batteries in the device. During today's visit all hazardous materials and toxins are kept out of reach from children and are not accessible. The preschool shares the bathroom with the church. There is one fully charged fire extinguisher in the hallway. The learning materials are organized, and toys are kept in safety bins and cabinets for easy access for the children.

LPAs observed the outdoor play area which consist of play structure with a slide. There is soft cushion material all around the play yard to absorb falls. There was a swing that was not anchored to the ground outside. The outdoor play area is also fenced all around with secured gates. There are no bodies of water on the premises. There are no firearms on premises.

Continued on 809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: AB'S PRESCHOOL AND DAYCARE
FACILITY NUMBER: 013422012
VISIT DATE: 11/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The children bring their own lunch and snacks from home. The kids bring their own water bottles. Water is refilled in the children’s bottles as necessary throughout the day. The center has not completed their lead testing.

At 10:00AM LPAs reviewed 5 children’s files and 1 staff files. The 1 out of the 5 children's files had no paperwork filled out or signed by parent (Admission agreement, LIC613A, LIC627, LIC995, LIC700, LIC702, LIC701 and immunization records). The Directors file and 1 staff file were not at the facility and could not be provided at the time of visit. LPAs could not verify the qualifications of one teacher because the file was not on site and could not be provided during inspection. LPAs reviewed sign in and out log. 4 children were not signed in and 2 children just had the time but no signatures. The facility conducts disaster drills at least every 6 months. The last drill was conducted 5/15/2023. LPA advised staff that a new drill should be conducted this week.

There were 12 deficiencies cited on today's inspection. See 809-D for deficiencies.



To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.


Continued on 809-C


SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: AB'S PRESCHOOL AND DAYCARE
FACILITY NUMBER: 013422012
VISIT DATE: 11/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP).

CCC DID NOT COMPLETE TESTING PRIOR TO THEIR DEADLINE

LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing InformationLPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and- resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.


Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative Faye Toms.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 11/13/2023 02:13 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 11/13/2023 at 12:55 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: AB'S PRESCHOOL AND DAYCARE
FACILITY NUMBER: 013422012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above the carbon monoxide detector was not opearational which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Director will send a video of the functioning carbon monoxide detector to LPA by email by POC date.
jaleesa.jackson@dss.ca.gov
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview, the licensee did not comply with the section cited above lead water testing was not complete before deadline which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2023
Plan of Correction
1
2
3
4
Director will have the drinking water tested for lead before the POC date and submit all the required documents from the PIN to LPA by email.
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:Jason Jang
LICENSING EVALUATOR NAME:Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 11/13/2023 02:13 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 11/13/2023 at 12:55 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: AB'S PRESCHOOL AND DAYCARE
FACILITY NUMBER: 013422012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239(o)
Fixtures, Furniture, Equipment and Supplies
(o) Playground equipment shall be securely anchored to the ground unless it is portable by design.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 swing set was not anchored to the ground which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee will get rid of swing set and submit proof to LPA by email.

jaleesa.jackson@dss.ca.gov
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation,interview, and record review, the licensee did not comply with the section cited above in 3 staff did no have current mandated reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Director and 2 staff will submit completed mandated reporter training to LPA by POC date by email.
jaleesa.jackson@dss.ca.gov
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:Jason Jang
LICENSING EVALUATOR NAME:Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 11/13/2023 02:13 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 11/13/2023 at 12:55 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: AB'S PRESCHOOL AND DAYCARE
FACILITY NUMBER: 013422012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(d)
Personnel Records
(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in 2 staff did not have files on site which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee will write and submit a statement to LPA by email by POC date. Statement should include that files need to be kept on site at all times for licensing. Licensee will email employee's missing file to LPA by email.
jaleesa.jackson@dss.ca.gov
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 5 children did not have any licensing forms filled out which poses/posed a potential health, safety or personal rights risk to persons in care.d
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee will provide a complete file for the child will an incomplete file to LPA by email by POC date. (LIC700, LIC701, LIC702, LIC613A, LIC995, LIC627, and Immunization records)
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:Jason Jang
LICENSING EVALUATOR NAME:Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 11/13/2023 02:13 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 11/13/2023 at 12:55 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: AB'S PRESCHOOL AND DAYCARE
FACILITY NUMBER: 013422012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220.1(g)
Immunizations
(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 5 children did not have any licensing forms filled out which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee will provide a complete file for the child will an incomplete file to LPA by email by POC date. (LIC700, LIC701, LIC702, LIC613A, LIC995, LIC627, and Immunization records)
Type B
Section Cited
CCR
101221(a)
Child's Records
(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 5 children did not have any licensing forms filled out which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee will provide a complete file for the child will an incomplete file to LPA by email by POC date. (LIC700, LIC701, LIC702, LIC613A, LIC995, LIC627, and Immunization records)
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:Jason Jang
LICENSING EVALUATOR NAME:Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 11/13/2023 02:13 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 11/13/2023 at 12:55 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: AB'S PRESCHOOL AND DAYCARE
FACILITY NUMBER: 013422012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 5 children did not have any licensing forms filled out which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee will provide a complete file for the child will an incomplete file to LPA by email by POC date. (LIC700, LIC701, LIC702, LIC613A, LIC995, LIC627, and Immunization records)
Type B
Section Cited
CCR
101223(b)(1)
Personal Rights
(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 5 children did not have any licensing forms filled out which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee will provide a complete file for the child will an incomplete file to LPA by email by POC date. (LIC700, LIC701, LIC702, LIC613A, LIC995, LIC627, and Immunization records)
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:Jason Jang
LICENSING EVALUATOR NAME:Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 11/13/2023 02:13 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 11/13/2023 at 12:55 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: AB'S PRESCHOOL AND DAYCARE
FACILITY NUMBER: 013422012

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 6 out of 6 children were not signed in correctly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee will write and submit a statement on how she will remain compliance in the future. Licensee will email statement to LPA by POC date.
jaleesa.jackson@dss.ca.gov
Type B
Section Cited
CCR
101216(g)(1)
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:

Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above in 1 staff member does have LIC503 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/27/2023
Plan of Correction
1
2
3
4
Licensee will provide complete LIC503 for staff member who's file was not provide to LPAs at time of inspeciton. Licensee will email to LPA by email by POC date.
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:Jason Jang
LICENSING EVALUATOR NAME:Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2023


LIC809 (FAS) - (06/04)
Page: 9 of 12