015700550-2-23-2024-52-CC-CURE-D2QS7U-20240223123806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015700550
Report Date: 02/23/2024
Date Signed: 02/23/2024 12:38:12 PM

Document Has Been Signed on 02/23/2024 12:38 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	PILGRIM LEARNING ACADEMY		FACILITY NUMBER:	015700550
ADMINISTRATOR:	VERVILLE, SHELLY		FACILITY TYPE:	850
ADDRESS:	20613 STANTON AVENUE		TELEPHONE:	(510) 581-1580
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94546
CAPACITY: 54	TOTAL ENROLLED CHILDREN: 24	CENSUS: 18	DATE:	02/23/2024
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Shelly Verville		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 02/23/2024 at 8:45am, Licensing Program Analyst (LPA) Christina Uribe conducted a Plan of Correction visit to the facility and met with Site Director, Shelly Verville. Also present during today's inspection is 4 staff and 18 children. The purpose of today's visit is to review the plan of corrections that were given during an annual required inspection on 01/19/2024. On 01/19/2024, the facility was issued 3 Type B Violations, (1. Mandated Reporter certificates not completed for 5 staff members; 2. Health Screening Report (LIC 503) forms and/or proof of TB clearance not obtained for 4 staff members; & 3. Proof of immunization against Measles (MMR) and/or Pertussis (Tdap) not obtained for 2 staff members). The facility was also issued 3 Advisory Notes (Technical Violations), (1. Some children's files had incomplete documents; 2. One child's prescription aero chamber to aide in the administration of inhaled medication has expired; & 3) Employee Rights (LIC 9052) forms not obtained for 3 staff members). During today's visit, LPA Uribe reviewed staff and children's files for completion. The Type B Violation for 2 staff members needing to obtain proof of immunization against Measles (MMR) and/or Pertussis (Tdap) is being cleared today as the facility has met the plan of correction. The Type B Violation for the Mandated Reporter certificates will not be cleared today as the plan of correction was not met. 4 out of the 5 staff members have obtained a Mandated Reporter certificate for Child Care Providers and one staff member only obtained a certificate for General Training. The Type B Violation for the Health Screening Report (LIC 503) forms and proof of TB Clearance will not be cleared today as the plan of correction was not met. 3 out of the 4 staff members have obtained a Health Screening Report (LIC 503) and proof of a TB Clearance. One staff member has proof of an upcoming appointment on 02/26/24 to perform a TB test. Page 1 of 2 *Continued on LIC 809C*

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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: PILGRIM LEARNING ACADEMY	FACILITY NUMBER: 015700550
	VISIT DATE: 02/23/2024

NARRATIVE

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The 3 Advisory Notes issued were also addressed and reviewed by LPA Uribe. The advisory note for children's files were corrected. The advisory note for the expired aero chamber for one child has been corrected. And the advisory note for the Employee Rights (LIC 9052) forms were corrected.

During today's visit, facility representatives asked for consultation for a number of topics. LPA Uribe discussed these topics for clarification. LPA Uribe also reviewed one newly enrolled child's file for consultation on the immunization records obtained. One newly hired staff member's file was also reviewed and LPA Uribe reviewed transcripts and signed the Evaluation of Teacher Qualifications (LIC 9095) form. This new employee was hired on 02/05/24 and has 90 days from the hire date to obtain a Mandated Reporter certificate for Child Care Providers.

During the 01/19/24 visit, LPA Uribe informed the director that the annual licensing fees were overdue and need to be paid. During today's visit, the director provided proof to LPA Uribe that the licensing fees were paid in full on 01/23/24.

In summary, LPA cleared one Type B Deficiency and provided the director with the clearance letter. The other two Type B Deficiencies are still in the process of meeting the plan of correction. The director will obtain the new certificate for the Mandated Reporter certificate for Child Care Providers for one staff and proof of TB clearance for one staff. Director will email these documents to LPA Uribe at Christina.Uribe@dss.ca.gov no later than the due date of 02/29/2024. If this due date is not met, the facility will be subject to additional citations being issued.

Notice of Site Visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview was conducted and report was reviewed with the director, Shelly Verville.

Page 2 of 2 ***End of Report***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC809 (FAS) - (06/04)

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