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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408864
Report Date: 04/10/2023
Date Signed: 04/10/2023 10:14:43 AM

Document Has Been Signed on 04/10/2023 10:14 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:
073408864
ADMINISTRATOR:GRICELDA MITCHELLFACILITY TYPE:
850
ADDRESS:1620 NERLOY RD.TELEPHONE:
(925) 261-6717
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY: 114TOTAL ENROLLED CHILDREN: 62CENSUS: 35DATE:
04/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:KIm Kotas TIME COMPLETED:
10:30 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 Regional Program Quality Manager KIm Kotas.

The facility reported that during outdoor play time a staff brought three children into the classroom to use the restroom. When transitioning from the classroom back outside one child was left in the classroom without supervision. It was discovered that the child was alone in the classroom by a parent. The facility reported the incident to both Community Care Licensing (CCL) and to the parent of the child that was left without supervision.

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.

During the visit is was also determined that S1 did not have the required clearance to work in a child care center. A civil penalty of $100 is assessed today.

A civil penalty of $250.00 is assessed today for a repeat violation. Facility was previous cited on 9/14/22 under California Code of Regulation, title 22 101229(a)(1)

Notice of Site Visit was provided and must be posted for 30 days.
Exit interview and report reviewed with KIm Kotas
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE: DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2023
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 04/10/2023 10:14 AM - It Cannot Be Edited


Created By: Cherie Acosta On 04/10/2023 at 09:47 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: 073408864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2023
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
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Facility shall develop a written plan of action to ensure there are no future incident. Facility shall submit a copy of the written plan to CCL by 4/11/23.
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time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. his requirement was not met as evidenced by: A child was left in the classroom without supervision which poses an immediate risk to the health and safety of children in care.

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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
Type A
04/11/2023
Section Cited
CCR101170(e)(1)

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
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S1 left the facility during the inspection. Facility shall submit a letter to CCL by 4/11/23 ensuring that it s understood and they shall ensure individuals will not be present at
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Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by: S1 did not have the required clearance to work in a child care center.
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the facility until proper clearance is obtained
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: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023


LIC809 (FAS) - (06/04)
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