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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423041
Report Date: 07/14/2023
Date Signed: 07/14/2023 02:27:31 PM

Document Has Been Signed on 07/14/2023 02:27 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:EXTENDED DAY CHILD CARE COTTONWOOD CREEKFACILITY NUMBER:
013423041
ADMINISTRATOR:PAULY, ASHLEYFACILITY TYPE:
840
ADDRESS:2400 CENTRAL PARKWAYTELEPHONE:
(925) 479-0785
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 75TOTAL ENROLLED CHILDREN: 75CENSUS: 30DATE:
07/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Katie SchaefferTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Jyoti Saini met with facility representative, Katie Schaeffer for an unannounced Annual Random Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the facility representative, Katie Schaeffer. Present during the inspection, director and 6 staff members supervising 30 children. The program consists of two sessions: 7:00am to 9:00am and 12:00 pm to 6:00 pm Monday - Friday in Modular L-100 on the COTTONWOOD ELEMENTARY SCHOOL CAMPUS. The facility currently operating summer program: Monday – Friday 7:00am to 6:00pm.
The facility was inspected indoor and outdoor today for health and safety hazards and the following was observed; There are no bodies of water, firearms, or weapons on the premises. The center is in good condition with proper temperature and ventilation and is free of any hazards. All furniture is in good repair. The Center has age-appropriate toys and equipment. The children and staff have a separate bathroom. The bathrooms appear to be safe, sanitary, and free of any hazardous items. There is drinking water readily available through water fountain and water bottles brought from home. There is a menu posted for the entire month. The facility serves snacks and children requires to bring their own lunch. LPA reviewed storage of food and observed all food is in original packaging or labeled with expiration date.
The classroom has appropriate postings. The last Emergency Drill was conducted on 07/12/2023 at 11:15am and is properly logged. Outdoor play area was free of hazards. Facility understands not to commingle with Elementary School children. The facility uses electronic sign in and sign out system which is KT connect. The center has a complete record of sign-in/out sheets by an authorized pick-up person. There are multiple first aid kits available. There is a working fire alarm system at the elementary. The room has a working smoke and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone available. All children have a record of emergency identification information. Staff records reviewed were complete. All staff has a criminal record clearance on file. The site Director and staff has a current Pediatric First Aid/CPR certificate on file. The director understands that the opening and closing staff must have a current Pediatric First Aid/CPR certificate on file. All staff has taken Mandated Reporter training. LPA reviewed the facility roster and copy was obtained.

see next page...

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: EXTENDED DAY CHILD CARE COTTONWOOD CREEK
FACILITY NUMBER: 013423041
VISIT DATE: 07/14/2023
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During inspection,

Criminal Record Clearance -

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.

Incidental Medical Services (IMS)


This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and
administrative records.
For IMS information see PIN 22-02-CCP. 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/.
MyChildCarePlan.org
Facility representative were informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

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.

No deficiency was cited Today.


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, Katie Schaeffer.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC809 (FAS) - (06/04)
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