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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700546
Report Date: 08/04/2021
Date Signed: 08/04/2021 03:38:09 PM

Document Has Been Signed on 08/04/2021 03:38 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:ADVENTURE TIME EXTENDED DAYCARE-GOLDEN OAKFACILITY NUMBER:
015700546
ADMINISTRATOR:ALBERT, MIMIFACILITY TYPE:
840
ADDRESS:2652 VERGIL COURTTELEPHONE:
(510) 304-4151
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY: 75TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/04/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Mimi AlbertTIME COMPLETED:
03:55 PM
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A Prelicensing Inspection was conducted today 8/4/2021 by Licensing Program Analyst (LPA) Melanie Otsuji. LPA met today with Executive Director/Applicant, Mimi Albert. The applicant has submitted an application for a school-age license. The school-age program is located on Hayward Twin Oaks Montessori Elementary School, and will be operating in room K and Multi-Purpose Room. Hours of operation will be from 7:00AM-6:00PM, Monday through Friday. A health and safety inspection was conducted inside and outside.

INDOORS: EXEMPT
OUTDOORS: EXEMPT

A fire clearance was approved by the Alameda County Fire Department on 7/7/2021.


The classrooms are equipped with age appropriate materials and equipment. As a school age program on a functioning school site, this facility is exempt from measurement, bathroom, isolation and fencing requirements. The yard is fenced in all around and there are climbing structures. Tanbark is used for cushioning. Building overhang provide shade for the children in the play yard. There are sinks and toilets available for children and provide privacy. The facility serves snacks and there will be refrigeration. Drinking water is available inside and outside. The center has first aid supplies available. The sign in/out sheet allows for parents' and staff's full legal signature.

This facility plans to provide Individual Medical Services – IMS. A Plan of Operation that includes 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: http://www.ada.gov/childqanda.htm.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2021
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: ADVENTURE TIME EXTENDED DAYCARE-GOLDEN OAK
FACILITY NUMBER: 015700546
VISIT DATE: 08/04/2021
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Mandated reporter and appeal rights, civil penalties, unusual incident reporting and fingerprint requirements was discussed today. Applicant is also being informed of the web address (www.ccld.ca.gov) for downloading child care forms, and the director is encouraged to email ChildCareAdvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The Applicant is also reminded that mandated reporter training is required for all staff and is to be renewed every 2 years at www.mandatedreporterca.com.

Zero Tolerance policies are explained. Appeal Rights were also discussed and provided. The center is found to be clean, safe, sanitary, and in good repair.

A license for 75 children (operating out of Room K and Multi-Purpose Room) will be issued pending submission of the following documents:

- operable carbon monoxide on campus
- complete director packet

An exit interview was conducted.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC809 (FAS) - (06/04)
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