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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422740
Report Date: 10/11/2024
Date Signed: 10/11/2024 05:18:26 PM

Document Has Been Signed on 10/11/2024 05:18 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:BERGENDAHL, S. ANNETTEFACILITY NUMBER:
013422740
ADMINISTRATOR/
DIRECTOR:		BERGENDAHL, S. ANNETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 304-9570
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
10/11/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Annette BergendahlTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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On October 11, 2024 at approximately 2:50pm Licensing Program Analysts (LPA) Randy Miranda arrived unannounced for an annual inspection for health and safety. Present for the inspection was the licensee Annette Bergendahl, fingerprint cleared assistant, and 5 children (one infant; two 2-years-old; one 8-year-old; one 10-year-old) in care. The home is in ratio today. The hours of operation are Monday-Friday 7:00 AM to 6:00 PM.

The facility is a 3-bedroom, two bath single story home with an attached 2-car garage. It is rented by the licensee and contains a living room, dining room, kitchen, 3 bedrooms (including master bath), enclosed (fenced) backyard play area. There is a screened fireplace in the living room. The home is neat and clean with heating and ventilation for safety and comfort. Per the licensee, the ISOLATION AREA will be in middle bedroom next to the house bathroom away from the other children in care.



On-limit include: Kitchen, dining room, living room, daycare room (1st bedroom to right in hallway), hallway bathroom, backyard. Master bedroom and middle bedroom (next to the house bathroom bedroom) only used for napping infants in cribs. Licensee was reminded that other than wipes or things used for the children in the on limits children’s bathroom, they need to be empty of most items (or locked up) such as cleaning products. There are no accessible hazardous cleaning chemicals or other liquids in the on-limits area.

Off-limits include: Attached 2-car garage, locked shed and locked storage unit in backyard, both gated side yards and front yard (other than to walk through for drop off and pick up times). Off limit areas are inaccessible by closed and/or locked doors and visual supervision

All licensing documents required to be posted in a public place were present behind the front entry door.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Randy Miranda
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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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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: BERGENDAHL, S. ANNETTE
FACILITY NUMBER: 013422740
VISIT DATE: 10/11/2024
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Licensee has ample age-appropriate toys and learning materials in the home. There is a fully charged fire extinguisher 3A40BC (inspected 9/19/2022). There is a working smoke and carbon monoxide detector (tested and functioning), and a working telephone. Disaster drills are conducted monthly, the last drill completed 7/17/2024. Licensee has a first aid kit in the main house bathroom.

Per licensee, there are no firearms in the home. LPA did not observe any bodies of water, hazardous materials, or toxins accessible to children on the premises during the inspection. The backyard play area has age-appropriate toys and playhouse structures with a patio and grass area. Licensee has three dogs kept in dog cages most of the day (per licensee vaccinations are up to date).

The Licensee’s Health and Safety training is completed and CPR and First Aid certificate expires on 11/18/2025 . The Licensee’s Mandated Reporter certificate expires on 8/19/2026. Licensee’s assistant’s Mandated Reporter certificate expires on 3/15/2026 while CPR and First Aid expires on 3/16/2026. The licensee and assistant are compliant with the immunization laws which pertains to day care.

LPA reminded the licensee of the following; Mandated Reporter training is to be renewed every two years, CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.



Children’s files reviewed and found to be mostly complete. Infant Safe Sleep Plan LIC 9227 is available in children’s files. Sleep logs for infants to document 15-minute checks are current. Licensee does not carry liability insurance, children’s files contained signed acknowledgement forms from parents.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Randy Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC809 (FAS) - (06/04)
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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: BERGENDAHL, S. ANNETTE
FACILITY NUMBER: 013422740
VISIT DATE: 10/11/2024
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing 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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

LPA discussed the safe sleep regulations with licensee 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 licensee 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.

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.

Licensee 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.

No deficiencies were issued during today’s inspection. This report will remain on file for 3 years.

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

Exit interview conducted and report was reviewed with the licensee Annette Bergendahl and assistant Jasmine Contreras.


SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Randy Miranda
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC809 (FAS) - (06/04)
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