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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073400100
Report Date: 06/17/2024
Date Signed: 06/17/2024 10:59:12 AM

Document Has Been Signed on 06/17/2024 10:59 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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:HOLY SHEPHERD COMMUNITY PRESCHOOLFACILITY NUMBER:
073400100
ADMINISTRATOR/
DIRECTOR:		KOEPER, SUSANFACILITY TYPE:
850
ADDRESS:433 MORAGA WAYTELEPHONE:
(925) 254-3429
CITY:ORINDASTATE: CAZIP CODE:
94563
CAPACITY: 53TOTAL ENROLLED CHILDREN: 55CENSUS: 46DATE:
06/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Amanda LyonTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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On 06/17/2024 at 9:00AM Licensing Program Analyst (LPA), A. Curry conducted an unannounced visit to follow up on a self-reported unusual incident where a child was served food the child was allergic to. LPA met with Office manager Amber Thompson and Assistant Director, Amanda Lyon, to explain the purpose of today's visit. LPA toured the facility and conducted interviews. Although staff indicated it was a rare occasion to serve foods children are allergic to, C1 has a known sunflower seed allergy and was served sun butter (See 809). Once facility was aware of the allergic reaction, staff immediately administered an Epi-Pen, contacted paramedics, and the child's authorized representative.

During today's visit, LPA also toured additional space that was added to the 2s classroom in the original building. The space is currently separated by a safety gate. LPA will follow up with Director, Claire Peterson, to verify if additional furniture will be added to the space. If additional furniture, equipment, and/or toys will be added to the space, LPA will inspect the space again once space is completely finished and ready to be used by children in care. The staff was informed to not use the space until the space has been approved for on-limit use.


Exit interview conducted, appeal rights were given, and report was reviewed with the Assistant Director, Amanda Lyon.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2024
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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Document Has Been Signed on 06/17/2024 10:59 AM - It Cannot Be Edited


Created By: Ashley Curry On 06/17/2024 at 10:45 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HOLY SHEPHERD COMMUNITY PRESCHOOL
FACILITY NUMBER: 073400100

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2024
Section Cited
CCR
101227(B)

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101227 Food Services (B) A child shall not be served any food to which the child's record indicates he/she has an allergy.


This requirement was not met as evidence by:
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By 07/01/2024 the facility will email LPA a written plan on how they will comply with the regulation, etc.. verifing allergies prior to serving any food.
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Based on interviews the facility did not comply with the section cited above by not ensuring children are not served foods they have a known allergy to, which poses a potential risk to health, safety, and personal rights of 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:Monica Mathur
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024


LIC809 (FAS) - (06/04)
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