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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423587
Report Date: 04/26/2023
Date Signed: 05/18/2023 08:59:14 AM

Document Has Been Signed on 05/18/2023 08:59 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:ANDRADA, MIYANIFACILITY NUMBER:
013423587
ADMINISTRATOR:ANDRADA, MIYANIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 332-8806
CITY:OAKLANDSTATE: CAZIP CODE:
94605
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
04/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Miyani AndradaTIME COMPLETED:
11:35 AM
NARRATIVE
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*** This is an amended version of the report dated 4/26/23:

On 4/26/23, at 9:45am, Licensing Program Analyst (LPA) Catherine Fernandes arrived unannounced on a case management inspection and met with the Licensee's assistant (S1) soon after Licensee Miyani Andrada arrived. Present in care were two infants and seven preschoolers with additional two finger print cleared staff members.
The purpose of the visit was based on an incident report that was sent by the Licensee regrading which occurred on 4/13/2023, where an infant (C1) bit another infant (C2) on face and was later placed in a high chair to prevent further injury or discomfort to the children in care. Licensee stated that the child (C1) was in the high chair eating a snack and was hours later.

Upon arrival LPA Fernandes observed two infants and two preschoolers in high chairs which is considered a restraint to the children in care. Staff members immediately removed the children from the high chairs and LPA Fernandes explained that the high chairs can only be used during feedings or snack times.

LPA Fernandes informed licensee Miyani Andrada that this report dated 4/26/23 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to personal rights of children in care. Also, LPA Fernandes informed the licensee Miyani Andrada to provide a copy of this licensing report dated 4/26/23 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

See 809D for deficiency cited

Exit interviewed conducted, Notice of site visit, Appeal rights and Report provided.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Catherine Fernandes
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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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Document Has Been Signed on 04/26/2023 11:30 AM - It Cannot Be Edited


Created By: Catherine Fernandes On 04/26/2023 at 11:00 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: ANDRADA, MIYANI
FACILITY NUMBER: 013423587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2023
Section Cited
CCR
102423(a)

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Personal Rights- Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. This requirement has not been met as evidenced by:
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Licensee will review the personal rights regulations and watch the videos for providers on the Community Care Licensing website then send a statement of completion to CCL by POC date.
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Based on LPA's observations five children in care were being restrained in high chairs which is an immediate risks to the personal rights of children.
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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:Catherine Fernandes
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023


LIC809 (FAS) - (06/04)
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