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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408285
Report Date: 08/05/2021
Date Signed: 08/05/2021 03:28:23 PM

Document Has Been Signed on 08/05/2021 03:28 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:KIDDIE ACADEMYFACILITY NUMBER:
073408285
ADMINISTRATOR:AUTUMN BROOKSFACILITY TYPE:
850
ADDRESS:8680 BRENTWOOD BLVD.TELEPHONE:
(925) 683-3369
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY: 120TOTAL ENROLLED CHILDREN: 0CENSUS: 28DATE:
08/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Autumn BrooksTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced case management inspection as a result of a self reported incident that occurred on 7/29/21. LPA met with center Director Autumn Brooks.

It was reported that during transition a teacher with 6 children was taking napping equipment from one classroom to another. During this transition C1 was left unattended in the classroom for approximately 1-2 minutes. C1's parent is a teacher at this center and is aware of the incident. The teacher involved in the incident was terminated.

The attached type A violation is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC 9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing

$500.00 civil penalty was assessed today.
Report reviewed with Autumn Brooks.
Appeal rights were provided.
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: 08/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2021
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 08/05/2021 03:28 PM - It Cannot Be Edited


Created By: Cherie Acosta On 08/05/2021 at 02:49 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: KIDDIE ACADEMY
FACILITY NUMBER: 073408285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2021
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time,
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Licensee shall submit a written plan of action to CCL by 8/6/21 explaining steps taken to ensure there are no further incidents.
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except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement was not met as evidenced by: during transition C1 was left unattended for 1-2 minute which poses an immediate risk to the health and safety of children in care.
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This is a zero tolerance violation. An immediate $500 is assessed today and $100 per day will be assessed until corrected. Subsequent zero tolerance violations are $1000 immediate civil penalty and $100 per day will be assessed 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: 08/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2021


LIC809 (FAS) - (06/04)
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