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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073401949
Report Date: 08/31/2022
Date Signed: 08/31/2022 03:39:58 PM

Document Has Been Signed on 08/31/2022 03:39 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:GAN ILAN PRESCHOOL - TEMPLE ISAIAHFACILITY NUMBER:
073401949
ADMINISTRATOR:COURTNEY LUDLOWFACILITY TYPE:
850
ADDRESS:945 RISA ROADTELEPHONE:
(925) 284-8453
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY: 95TOTAL ENROLLED CHILDREN: 95CENSUS: DATE:
08/31/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Courtney Ludlow TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst Nyeesha Blount and Licensing Program Manager Mayla Mendoza conducted an unannounced case management inspection for as a result of receiving an unusual incident report. LPA and LPM met with Director Courtney Ludlow.

See 809-D for Type A deficiency.

Exit interview conducted. A copy of report and appeal rights provided to Director Courtney Ludlow
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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 08/31/2022 03:39 PM - It Cannot Be Edited


Created By: Nyeesha Blount On 08/31/2022 at 02:47 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: GAN ILAN PRESCHOOL - TEMPLE ISAIAH
FACILITY NUMBER: 073401949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/31/2022
Section Cited
CCR
101223(a)(3)

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Personal Rights the Licensee shall ensure that each child is accorded the following personal rights: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of punitive nature including but not limited to: interference with functions of daily living including eating, sleeping, or toileting: or withholding of shelter, clothing, medication or aids to physical functioning.
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By POC due date 09/30/22 conduct personal rights training with staff signatures. submit to LPA Nyeesha Blount via email.
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This requirement is not met as evidenced by: interviews conducted revealed child was grabbed on the arm leaving marks This poses an immediate risk to the health and safety 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.
SUPERVISOR'S NAME:Mayla Mendoza
LICENSING EVALUATOR NAME:Nyeesha Blount
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022


LIC809 (FAS) - (06/04)
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