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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700583
Report Date: 02/13/2025
Date Signed: 02/13/2025 11:16:02 AM

Document Has Been Signed on 02/13/2025 11:16 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:BUILDING KIDZ OF DUBLINFACILITY NUMBER:
015700583
ADMINISTRATOR/
DIRECTOR:		SHUBRA GUPTAFACILITY TYPE:
850
ADDRESS:6351 DUBLIN BOULEVARDTELEPHONE:
(650) 777-5301
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 57DATE:
02/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Regional Manager Emaan IbeihTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jyoti Saini conducted an unannounced Case management inspection regarding an Unusual Incident Reported by the facility on 2/7/2025. LPA met with Regional Manager Emaan Isbeih and conducted the interviews. Present during the inspection were the facility in charge and 10 staff members supervising 57 children.

Based on the interviews conducted, the facility acknowledged that an incident occurred in which Child 1 (C1) was bitten by Child 2 (C2). Furthermore, it was determined that the facility failed to notify the parents. It is also concluded that the facility did not provide a safe and healthy environment for the children involved in the incident, leading to violations of the personal rights of the child who was bitten.

Two Type B deficiencies are cited today.

Appeal rights were provided.

A notice of site visit was posted and must remain posted for 30 days.

An exit interview was conducted with Regional Manager Emaan Isbeih.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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
Document Has Been Signed on 02/13/2025 11:16 AM - It Cannot Be Edited


Created By: Jyoti Saini On 02/13/2025 at 10:16 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: BUILDING KIDZ OF DUBLIN
FACILITY NUMBER: 015700583

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
101212(a)(f)

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101212 Reporting Requirements (f)The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.
This requirement is not met as evidenced by:
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The Facility shall watch the "Child Care Reporting Requirements" at www.ccld.childcarevideos.org and submit a written statement explaining when and how an event should be reported to the Community Care Licensing Division(CCLD) by the POC date.
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Based on observations, interviews, and record reviews, the Licensee did not comply with the section cited above. The facility failed to notify the parents about the incident involving their child, which poses a potential health and safety risk to the children in care.
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Type B
02/28/2025
Section Cited
CCR101223(a)(2)

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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by:
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The director and staff shall watch the Personal Rights Video on the CCLD website and formulate a plan to ensure children's safety. The facility shall submit a proof of staff meeting with discussed agenda points and staff attendance by POC date.
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Based on observations, interviews, and record reviews, the Licensee did not comply with the section cited above. The facility acknowledged an incident where C1 bit C2, resulting in violating C2's personal rights, which poses a potential health and safety risk to the children in care.
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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:Wynn Norona
LICENSING EVALUATOR NAME:Jyoti Saini
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2025


LIC809 (FAS) - (06/04)
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