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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408285
Report Date: 05/05/2023
Date Signed: 05/05/2023 11:17:26 AM

Document Has Been Signed on 05/05/2023 11:17 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
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: 91CENSUS: 55DATE:
05/05/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Autumn BrooksTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced visit in regards to a self reported incident. LPA met with Director Autumn Brooks.

The facility self reported that a child was left without supervision on 5/3/23 for approximately 10 minutes. The children were transitioning to the classroom from outside. During the transition a child was left on the play yard unsupervised.

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 (LIC9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.

This is a zero tolerance violation. This is a repeat violation within a 12 month period as the facility was previously cited under California Code of Regulations, title 22 section 101229(a)(1) on 8/4/22. An immediate $1000 is assessed today and $100 per day will be assessed until corrected.

Exit interview and report reviewed with Autumn Brooks.
Notice of Site Visit was provided.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE: DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/05/2023
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 05/05/2023 11:17 AM - It Cannot Be Edited


Created By: Cherie Acosta On 05/05/2023 at 10:13 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: KIDDIE ACADEMY
FACILITY NUMBER: 073408285

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2023
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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Director shall develop a written plan of action to ensure there are no further incidents. Director shall submit the plan of action to CCL by 5/8/23.
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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: a child was left on the play yard with out supervision which poses an immediate risk to the health and safety 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:Sherelle Johnson
LICENSING EVALUATOR NAME:Cherie Acosta
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023


LIC809 (FAS) - (06/04)
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