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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015700598
Report Date: 01/09/2025
Date Signed: 01/09/2025 03:45:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2024 and conducted by Evaluator Michael Mathew
COMPLAINT CONTROL NUMBER: 52-CC-20241112083421
FACILITY NAME:PLAY PALS SPACE, LLCFACILITY NUMBER:
015700598
ADMINISTRATOR:JACKSON, TAMILAFACILITY TYPE:
850
ADDRESS:14207 E. 14TH STREETTELEPHONE:
(510) 612-5862
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:30CENSUS: 11DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Tamila JacksonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Breach of Parent Handbook Contract
INVESTIGATION FINDINGS:
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13
On January 9,2025 at,1:15 PM Licensing Program Analyst (LPA) Michael Mathew conducted an unannounced inspection to conclude a complaint investigation LPA met with Director Tamila Jackson and advised her the purpose of the inspection. Director provided LPA a tour of the facility inside and out. There were 11 children and 3 staff in care at the time of the inspection.

LPA interviewed staff members, parents, and reporting party .Based on interviews conducted, observations, and record review the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1, Article 06, Section: 101219(f) Admission Agreements, are being cited on the attached LIC 9099D.

A notice of site visit and appeal rights were given. Exit interview conducted and report was reviewed with Director Tamila Jackson
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Michael Mathew
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/12/2024 and conducted by Evaluator Michael Mathew
PUBLIC
COMPLAINT CONTROL NUMBER: 52-CC-20241112083421

FACILITY NAME:PLAY PALS SPACE, LLCFACILITY NUMBER:
015700598
ADMINISTRATOR:JACKSON, TAMILAFACILITY TYPE:
850
ADDRESS:14207 E. 14TH STREETTELEPHONE:
(510) 612-5862
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:30CENSUS: 11DATE:
01/09/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Tamila JacksonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Violation of Personal Rights by Disclosing Other Children's Diagnoses
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On January 9,2025 at, 1:15 PM Licensing Program Analyst (LPA) Michael Mathew conducted an unannounced inspection to conclude a complaint investigation. LPA met with Director Tamila Jackson and advised her the purpose of the inspection. Director provided LPA a tour of the facility inside and out. There were 11 children and 3 staff in care at the time of the inspection.

During the investigation, LPA interviewed staff members,Parents, and reporting party. Based on interviews conducted, and observations. there is not a preponderance of evidence to prove the alleged violation did or did not occur, meaning the allegations may have happened or are valid. Therefore, the allegations are deemed UNSUBSTANTIATED.

A notice of site visit and appeal rights were given. Exit interview conducted and report was reviewed with Director Tamila Jackson
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Michael Mathew
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 52-CC-20241112083421
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PLAY PALS SPACE, LLC
FACILITY NUMBER: 015700598
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2025
Section Cited
CCR
101219(f)
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The licensee shall comply with all terms and conditions set forth in the admission agreement.
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Director Stated that director will send an updated admission agreement to LPA via email by end of day 1/15/25. Director will be also providing updated admissions agreement to current and future parents.
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This requirement was not met as evidenced by:
Based on record review, the center terminated a family which did not corrolate with the admission agreement which could pose a potential health and safety risk to 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.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Michael Mathew
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3