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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423120
Report Date: 12/29/2021
Date Signed: 12/29/2021 11:30:45 AM

Document Has Been Signed on 12/29/2021 11:30 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:DOLMA CHILD CARE CENTERFACILITY NUMBER:
013423120
ADMINISTRATOR:PALDON, TENZINFACILITY TYPE:
830
ADDRESS:1700 - 7TH STREETTELEPHONE:
(510) 414-8447
CITY:BERKELEYSTATE: CAZIP CODE:
94710
CAPACITY: 6TOTAL ENROLLED CHILDREN: 6CENSUS: 0DATE:
12/29/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Tenzin PaldonTIME COMPLETED:
11:55 AM
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A Prelicensing Visit was conducted today by Licensing Program Analysts (LPA), Melissa Domantay and Melissa Guirit. LPAs met with applicant, Tenzin Paldon. The applicant submitted an application for an infant license. A health and safety inspection was conducted inside and outside. The center has also applied for a preschool program on-site (license #013423125). The infant program will operate in 1 classroom, Monday to Friday from 8:00am-6:00pm. The measurements are as follows:

INDOORS: 558.45 square feet = 16 children
OUTDOORS: 651.18 square feet = 8 children
A fire clearance, with a total capacity of 6 infants, ages birth to 24 months was received from the Berkeley Fire Department.

Infant classroom is equipped with varied age appropriate materials and equipment. The infant program will serve crib-aged infants. There is a separate crib area with 4 cribs for infants. The diaper changing counters are within arms reach of a sink. There is 1 sink and 1 toilet available in the infant area. The staff break room will serve as the isolation area for ill children. Play yard will be shared between infants and preschoolers, Applicant will provide a play yard schedule for each program to make sure infant and preschoolers do not commingle.The yard is fenced in all around. Photos of mats in infant play yard will be provided by applicant. Infants will utilize play yard except the climbing dome structure. Infant families will provide food for infants. There is a kitchen available. There is a washer and dryer to launder bedding daily; facility provides sheets. Facility will utilize paper sign in/out.

The facility has a fully charged 2A10BC fire extinguisher, working fire alarm and carbon monoxide detector, and first aid supplies. There is a working telephone at the center.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Melissa Domantay
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: DOLMA CHILD CARE CENTER
FACILITY NUMBER: 013423120
VISIT DATE: 12/29/2021
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Applicant is reminded that if facility plans to provide Incidental Medical Services a plan should be provided. – IMS. A Plan of Operation that includes IMS has been 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: http://www.ada.gov/childqanda.htm.

Gerelbat Zorigh will be considered a fully-qualified infant director once his required class is completed in March 2022. An exception has been approved by Licensing Program Manager (LPM) Mayla Mendoza for Director Gerelbat Zorigh. Gerelbat has completed 16 hours of health and safety training including pediatric CPR and First Aid and Lead Poisoning.

Mandated reporter, appeal rights, civil penalties, unusual incident reporting, fingerprint requirements, and COVID protocols were discussed today. Licensee is also being informed of the web address (www.ccld.ca.gov) for downloading child care forms, and checking Provider Information Notices (PINs). The director is encouraged to email ChildCareAdvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The director is also reminded that mandated reporter training is required for all staff and is to be renewed every 2 years at www.mandatedreporterca.com.

A license for 6 infant children will be effective today 12/29/21. An exit interview was conducted, and a copy of the report was provided to applicant/owner Tenzin Paldon.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Melissa Domantay
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2021
LIC809 (FAS) - (06/04)
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