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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073401306
Report Date: 05/17/2023
Date Signed: 05/17/2023 04:06:30 PM

Document Has Been Signed on 05/17/2023 04:06 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:KINDERCARE LEARNING CENTERFACILITY NUMBER:
073401306
ADMINISTRATOR:PAMELA SOUZAFACILITY TYPE:
850
ADDRESS:4308 FOLSOM DRIVETELEPHONE:
(925) 754-3137
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY: 72TOTAL ENROLLED CHILDREN: 48CENSUS: 41DATE:
05/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Jamari FredenburgTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced Case Management visit. LPA met with Director Jamari Fredenburg.

During the course of a complaint investigation it was determined that the facility did not provided incident reports to a child's authorized representative when a child received a minor injury while in care. There was no documentation of the incidents that occurred at the facility.

See 809-D for deficiency cited today.
Exit interview conducted and report reviewed with Jamari Fredenburg.
Notice of Site Visit was provided and must be posted for 30 days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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 05/17/2023 04:06 PM - It Cannot Be Edited


Created By: Cherie Acosta On 05/17/2023 at 03:21 PM
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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 073401306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
HSC
101226(a)(2)

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Health related Services. The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch. The licensee shall obtain specific instructions from the authorized representative regarding action to be taken.
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Director shall develop a written plan to ensure all incidents are documented and authorized representatives are notified of incidents. Director shall submit a copy of this plan to CCL by 5/26/23
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In the case of less serious injuries including, but not limited to, minor cuts, scratches and bites from other children requiring assessment and/or administration of first aid by staff, the licensee shall document the injury in the child's record and notify the child's authorized representative of the nature of the injury when the child is picked up from the center.
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• Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Cherie Acosta
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2023


LIC809 (FAS) - (06/04)
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