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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700527
Report Date: 08/11/2022
Date Signed: 08/11/2022 02:40:12 PM

Document Has Been Signed on 08/11/2022 02:40 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:CREATIVE WORLDFACILITY NUMBER:
015700527
ADMINISTRATOR:JACKSON, AMARISFACILITY TYPE:
850
ADDRESS:14830 WASHINGTON AVENUETELEPHONE:
(510) 567-3733
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 14DATE:
08/11/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Sugar PorterTIME COMPLETED:
02:45 PM
NARRATIVE
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On Thursday 8/11/2022 at approximately 9am, Licensing Program Analyst(LPA) Sabina Dodoo and Licensing Program Manager(LPM) Chandra Charles conducted an Announced Case Management Visit at Creative World Preschool. The census at time of the visit was 14 children and 5 staff members who are all fingerprint cleared and associated. LPA Dodoo and LPM Charles met with Interim Director Sugar Porter. The purpose of the visit was to review all facility staff files.

LPA Dodoo and LPM Charles reviewed 7 staff files to verify which staff members are fully qualified teachers. Upon review 2 staff members are fully qualified teachers, 2 staff members are partially qualified teachers, and 3 staff members are qualified teacher aides. The files had the following forms missing: LIC 501(Personnel Record), LIC 503(Health Screening), and Mandated Reporter Training certificates. S1, S2, S3, and S4 do not have a valid Mandated Reporter Training certificate in the staff files. S1, S2, S3, S4, S5, S6 and S7 do not have LIC 501 forms and LIC 503 forms in their staff files.

The following forms were presented to Interim Director Sugar Porter: LIC 311 -Records to be Maintained at the Facility Child Care Centers, School Age Centers and Child Care Centers for Mildly Ill Children, LIC 9095 Evaluation of Teacher Qualifications, Copy of the Title 22 Teacher Aide Qualifications and Duties Regulations, Teacher Qualifications and Duties Regulations, and Child Care Center Directors Qualifications and Duties.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Sabina Dodoo
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CREATIVE WORLD
FACILITY NUMBER: 015700527
VISIT DATE: 08/11/2022
NARRATIVE
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During today's inspection two Type B citations were given to the facility. The center is in violation of Health and Safety Code 1596.8662 (b)(1)Mandated Reporter Training Certificate Missing from Staff Facility Files(AB1207 Child Care Provider). The center is also in violation of California Code of Regulations 101216 (g)(2) Health Screening Report (Please See 809 D Citation Page).

Exit interview was conducted with Interim Director Sugar Porter. A copy of this report was given. Appeal Rights was printed and handed to Interim Director Sugar Porter. This report shall remain on file for the next 3 years.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Sabina Dodoo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/11/2022 02:40 PM - It Cannot Be Edited


Created By: Sabina Dodoo On 08/11/2022 at 12:53 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: CREATIVE WORLD

FACILITY NUMBER: 015700527

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2022
Section Cited
HSC
1596.8662(b)(1)

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1596.8662 (b)(1)On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child 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 has not been met as evidenced by:
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LPA and Interim Director Sugar Porter agreed that each staff member must complete their mandated reporter training before 08/25/2022
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Based on file reviews 4 staff(S1, S2, S3 and S4) members did not have a valid mandated reporter certificate in their facility staff file.This poses a potential health, safety and personal rights risk to children in care.
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Interim Director must email proof of certificates from each staff to LPA before 08/25/2022 at the following address: sabina.dodoo@dss.ca.gov
Type B
08/25/2022
Section Cited
CCR101216(g)(2)

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101216 (g)(2) Personnel Requirements All personnel, including the licensee, administrator and volunteers, shall be in good health ... capable of performing assigned tasks. (2)Each person specified in (g) above shall have a health-screening report signed by the person performing the screening.
This requirement is not met as evidenced by:
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Interim Director and LPA agreed that all 7 staff members must complete a health screening signed
by a physician before 08/25/2022.
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Based on file reviews conducted by LPA and LPM all 7 staff members did not have an LIC 503 Health Screening form signed by a physician located in their file. This poses a potential health, safety and personal rights risk to children in care.
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Interim Director must scan email the signed LIC 503 forms for each staff member to LPA before 08/25/2022 at the following email address: sabina.dodoo@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:Chandra Charles
LICENSING EVALUATOR NAME:Sabina Dodoo
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022


LIC809 (FAS) - (06/04)
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