california department of social services facility evaluation report ... · pdf filenarrative 1...

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STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

FACILITY NAME: HEARTS LEAP ICRI PRESCHOOL ADMINISTRATOR: MASH HOUR, ELLIE ADDRESS: 2638 COLLEGE AVENUE CITY: BERKELEY CAPACITY: 70 TYPE OF VISIT: Annual/Random MET WITH: Ellie Mashhour and Grace Frisbie

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

CCLD Regional Office, 1515 CLAY STREET, SUITE 1102 OAKLAND, CA 94612

STATE:CA CENSUS: 65 UNANNOUNCED

FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE: TIME BEGAN: TIME COMPLETED:

013416236 850

(510) 549-1422 94704

06/13/2014 09:00AM 11:45 AM

NARRATIVE 1 (2) An unannounced Annual/Random site visit was conducted by LPA Susan Neeson. Met with Ellie 2 Mashhour. 31 staff are fingerprint cleared and associated with the file although some are no longer working 3 here and need to be deleted from the personnel list. Ten staff are currently certified with CPR and First Aid 4 through 2/15. 5 6 The four classrooms were inspected, children's bathrooms were inspected. The two play yards were 7 inspected. The children's bathrooms all contained adequate toilet paper, soap and paper towels. There are 8 first aid kits in each classroom. There is presently only one child, in the Cypress room, who has prescription 9 medication, an Epipen. It is stored on a high shelf in the bathroom and all the staff have been trained on how 10 to use it. 11 12 The classrooms contain sufficient toys and equipment for children in care. All classroom equipment is in good 13 condition and plentiful. The yards were inspected, They contain sufficient toys and equipment for children. 14 The high climbing structures have resilient material underneath. The tree house is a new structure since last 15 visit. It is secure and safe. Drinking water is available in each classroom and on the yard. There is shade on 16 the yard from mature trees and shade structures. 17

· 18 Record keeping was discussed. All required forms were not posted. By the end of the visit all required forms 19 were posted. Gave copy of LIC 311 A which outlines which forms need to be posted. 20 21 The following blank forms were issued and updates were requested: LIC 215, 309,308, 610. Blank copy of 22 roster was issued. Received LIC 500 during visit. Copy of Regulation 101227 was issued. 23 24 AB 633 was issued. New car seat information was issued. Fire/Earthquake drill blank form was issued. 25

No deficiencies are observed. An exit interview was given. SUPERVISOR'S NAII/lE: Diane Perez

LICENSING EVALUATOR NAME: Susan Neeson

LICENSING EVALUATOR SIGNATURE:

Stlt 1\1 ~

TELEPAONET (51 0) 622-2592

TELEPHONE: (510) 622-2630

DATE: 06/13/2014

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

~ DATE: 06/13/2014

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 {FAS) - (06/04) Page: 1 of 1

0



FACILITY NAME: HEARTS LEAP ICRI PRESCHOOL ADMINISTRATOR: MASHHOUR, ELLIE ADDRESS: 2638 COLLEGE AVENUE CITY: BERKELEY STATE: CA CAPACITY: 70 CENSUS: 66

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FACILITY NUMBER: FACILITY TYPE: TELEPHONE: ZIP CODE: DATE:

TYPE OF VISIT: Annual/Random UNANNOUNCED TIME BEGAN:

013416236 850

(510) 549-1422 94704

04/28/2011 08:00AM 12:30 PM MET WITH: Christopher Taffe, Ellie Mashhour, Gretchen Stites TIME COMPLETED:

NARRATIVE 1 An unannounced Annual/Random site visit was conducted by LPA Susan Neeson. Met with several staff 2 before Ellie Mashhour arrived. 3 4 All staff are fingerprint clear as required. It is suggested that the Licensee, whomever that is, be associated 5 with the facility. LIC 309 needs to be updated for the file. 6 7 The four classrooms were inspected, children's bathrooms were inspected. The two play yards were 8 inspected. The children's bathrooms all contained adequate toilet paper, soap and paper towels. There are 9 first aid kits in each classroom. Medications were reviewed. 10 11 Record keeping was discussed. Sign-in/out procedures and record keeping were discussed at length. These 12 are ongoing issues. Ellie Mashhour stated that she will send in an updated LIC 500 for the file. 13 14 A sample of children's records were reviewed. Staff files were reviewed. Staff files were not complete, 15 although many required documents were in the files. Required forms were posted. 16 17 Copies of Regulations LIC 101238,101226 and 101229.1 were issued. 18 Deficiencies are cited on LIC 809 D. 19 20 Appeal Rights were discussed. 21 22 An exit interview was given. 23 24 25

SUPERVISOR'S NAME: Barbara Bobincheck



TELEPHONE: (51 0) 622-2602

TELEPHONE: (51 0)622-2625

~0}~ DATE: 04/28/2011



~ DATE: 04/28/2011


LIC809 (FAS) - (06/04) Page: 1 of2

0


FACILITY EVALUATION REPORT (Cont)

FACILITY NAME: HEARTS LEAP ICRI PRESCHOOL

DEFICIENCY INFORMATION FOR THIS PAGE:

Deficiency Type POC Due Date I DEFICIENCIES Section Number

1 Health related services Type B 2 1. LPA observed 3 outdated medications and 4

04/28/2011 3 medications lacking name and date of child. There

Section Cited 4 were two epipens lacking name of child and

101226e3ab 5 prescription information. 6 7

1 Buildings and grounds Type B 2 2. LPA observed a narrow space at back of

05/05/2011 3 playground which lacks a gate where a child might

Section Cited 4 go an be unseen. This area is between the Julia 5 Morgan Theater and the playground. This presents

101238 abc 6 a possible hazard to children. 7

1 Sign-in/out Type B 2 3. There are 4 children not signed-in today.

05/02/2011 3 4

Section Cited 5 101229.1 a 1 6

7

1 2 3 4 5 6 7

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FACILITY NUMBER: 013416236 VISIT DATE: 04/28/2011

PLAN OF CORRECTIONS(POCs)

1 These products were removed during visit and will 2 be returned to parents or destroyed. Ellie 3 Mash hour states that in the future all medications 4 will have child's name and date on them if not in 5 original prescription container. 6 7

1 Ellie Mashhour states that this will be corrected by 2 5/5/11. 3 4 5 6 7

1 Ellie Mash hour states that all children will be 2 properly signed-in by 5/2/11. 3 4 5 6 7

1 2 3 4 5 6 7

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: Barbara Bobincheck



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TELEPHONE: (510) 622-2602

TELEPHONE: (510)622-2625

DATE: 04/28/2011

I acknowledge receipt of this form and understand my appeal rights as explained and received.


~ DATE: 04/28/2011

LIC809 (FAS) - (06/04) Page: 2 of2

(-..._



FACILITY NAME: HEARTS LEAP ICRI PRESCHOOL ADMINISTRATOR:MASHHOUR, ELLIE ADDRESS: 2638 COLLEGE AVENUE CITY: BERKELEY CAPACITY: 70 TYPE OF VISIT: POC MET WITH: Gretchen Stites and Ellie Mashhour

0


BAY AREA-CC OAKLAND, 1515 CLAY STREET., SUITE 1102 OAKLAND, CA 94612



013416236 850

(510) 549-1422 94704

06/25/2009 01:15PM 03:30PM

NARRATIVE 1 The purpose of the visit is to determine if deficiencies cited 6/10/09 had been corrected. Met initially with 2 Gretchen Stites. Ellie Mashhour arrived later. 3 4 The facility was toured inside and out. Areas cited previously were inspected. 5 6 Record keeping was discussed. Sign-in/out procedures and record keeping were discussed at length. Ellie 7 Mashhour stated that she will be redesigning the method used to document sign-in/out and will send a letter 8 outlining whatever new procedures she decides to put in place. 9 10 Both deficiencies cited previously are observed as corrected. 11 12 A sample of children's records were reviewed. 13 14 No deficiencies are cited. 15 16 An exit interview was given. 17 18 19 20 21 22 23 24 25

SUPERVISOR'S NAME: Michele Byers



7s£_f\l~

TELEPHONE: (510)622-2646

TELEPHONE: (51 0)622-2625

DATE: 06/25/2009



~· DATE: 06/25/2009


LIC809 (FAS) - (06/04) Page: 1 of 1

0

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY

BAY AREA-CC OAKLAND 1515 CLAY STREET., SUITE 1102 OAKLAND, CA 94612

06/25/2009

HEARTS LEAP ICRI PRESCHOOL 013416236 2638 COLLEGE AVENUE BERKELEY, CA 94704

Letter of Deficiency Citations Cleared Dear Licensee,

0


The following deficiencies, initially cited during a visit on 06/10/2009, have been cleared:

Section Cited: 101238 c Date Due: 06/15/2009 Plan of Correction: Corrections: Gretchen Stites states that this will be corrected by 6/15/09. Cleared By Visit

Section Cited: 101238 c Date Due: 06/15/2009 Plan of Correction: Corrections: Gretchen Stites states that these items will be removed by 6/15/09. Cleared By Visit



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Clearance Date: 06/25/2009

Clearance Date: 06/25/2009

TELEPHONE: (51 0)622-2625

DATE: 06/25/2009

This report must be available at Child Care and Group Home facilities for public review for 3 years. Cleared POC Letter (FAS) - {04/05) Page: 1 of 1

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

0 0 .~-,

FACILITY VISIT SUMMARY REP~..,.-a Complaint Control Number:

FAC;:;;MT~ Lc=I'IP tcr<t ff~ l£il;~TONA<51tht?ur T&;~uvi~Z3?/FACI~;~~ pfs

ADDi~ 3 ~ CWlu~ /1{1z_._ &rkdu, 9tf70V /T(~;~)s-~q~ J~~zo ICE5Z--IDAT~/i5-;~" TYPE OF VISIT

0 Complaint

n Prelicensing

-(]~ 7 METJViTH: H - ' H- I L/U-1 I TIME BEGAN

0 Random (gr~ ~ 0 Announced I JJ It;" C)l POC I :TIM: COMPLETED

0 Required i ~ Unannounced I Is- z 'i Management 1 . /v

DEFICIENCY/CML PENALTY INFORMATION

U T~eA 0 0 Type 8 0 ~ No Deficiency Cited 0

Civil Penalty Assessed

Penalty Notice Given

Penalty Cleared

AREA OF DEFICIENCY(IES)

0 Umits of Ucense 0 Program/Operation

0 Criminal Record

0 Records 0 Health Related/Medical Services

0 Physical Plant

0 Food Service 0 Qualifications

Deficiency Description

SUP~ISOR'S NAME

;v;, ~~/5 LICENSING EV~fR NAME

:5. ;v~s-oAJ DATE

t:

0 Penalty Not Cleared

0 Deficiencies Cleared

0 Deficiencies Not Cleared

0 Staffing/Ratio

0 Care and Supervision 0 Personal Rights

0 Other

\To Be Corrected By Date

tz2 --),;1'

I have read and understand the electronic version of the full licensing report completed today at this facility. I acknowledge receipt of this form and understand my appeal rights as explained on the back of this form. If "A" violations are cited, child care providers must post this report pending receipt of final report.

DATE 6/2-s/ocr r----'

FOR LPA USE WHEN PROVIDING A PRINTED COPY OF THE ELECTRONIC REPORT TO THE LICENSEE:

I certify that the attached is a true and correct copy of the electronic field visit report completed at the facility

on ________________ =-~---------------(Date)

(LPA Signature) (Date)

LIC 8098 (8104) PAGE 1 OF 2

0



FACILITY NAME: HEARTS LEAP ICRI PRESCHOOL ADMINISTRATOR: MASHHOUR, ELLIE ADDRESS: 2638 COLLEGE AVENUE CITY: BERKELEY CAPACITY: 70 TYPE OF VISIT: Annual/Random MET WITH: Gretchen Stites


NARRATIVE

(


BAY AREA-CC OAKLAND, 1515 CLAY STREET., SUITE 1102 OAKLAND, CA 94612


013416236 850

(510) 549-1422 94704

06/10/2009 02:00PM 04:00PM

1 An unannounced Annual/Random site visit was conducted by LPA Susan Neeson. Met with Gretchen Stites. 2 3 Staff records were reviewed. Documents related to person in charge and those in charge when Director is not 4 present need to be mailed for the file. 5 6 The facility was toured inside and out. Facility was in ratio throughout the site visit. 7 8 Deficiencies are cited on LIC 809 D. 9 10 Appeal Rights were discussed. 11 12 An exit interview was conducted. 13 14 15 16 17 18 19 20 21 22 23 24 25




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TELEPHONE: (51 0)622-2646

TELEPHONE: (510)622-2625

DATE: 06/10/2009



~~ DATE: 06/10/2009


LIC809 (FAS) - (06/04) Page: 1 of2

~ '






1 Buildings and Grounds Type B 2 1. LPA observed area around and behind pine tree

06/15/2009 3 to be covered in thick branches which make an

Section Cited 4 area that cannot be supervised because the leaves 5 of the tree block area and provide a place to hide

101238 c 6 out of supervision of staff. 7

1 Buildings and Grounds. Type B 2 2. LPA observed some hazards on large

06/15/2009 3 playground that need to be removed: including a

Section Cited 4 broken rake and wood pieces and old equipment. 5

101238 c 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

f""

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION BAY AREA-CC OAKLAND,1515 CLAY STREET., SUITE 1102 OAKLAND, CA 94612



1 Gretchen Stites states that this will be corrected by 2 6/15/09. 3 4 5 6 7

1 Gretchen Stites states that these items will be 2 removed by 6/15/09. 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7





~N~

TELEPHONE: (510)622-2646

TELEPHONE: (510)622-2625

DATE: 06/10/2009



DATE: 06/10/2009

LIC809 (FAS) - (06/04) Page: 2 of2

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

FACILITY VISIT SUMMARY REPor' ("'

Complaint Control Numbc..

FA;z7~6 L ADMINISTRATOR

ADDRESS

~&3&: TYPE OF VISIT

0 Complaint

0 Prelicensing

0 Management

11-ve. r/3&[~ ~:-~ )fET WITH: \_ )

~j ~~~o~, ~ v/LJ/-4~ 0 Required

DEFICIENCY/CIVIL PENALTY INFORMATION

I TELEPHONE

5 C(Cf~/</22

"?2Sl Type A 0 Civil Penalty Assessed

0 Type 8 0 Penalty Notice Given

0 No Deficiency Cited 0 Penalty Cleared


0 Limits of License 0 Program/Operation

I FACILITY NUMBER / .-. FACILITY TYPE

c;3C/(w?-h

I CAPACITY I CENSUS -. I DATE/~ /- -.

jO ~? Uf!O /D9 0 , Announced f ""' ':~ G'V

~) Unannounced I Tl/o?ET~




0 Staffing/Ratio

0 Criminal Record

0 Records

0 Health Related/Medical Services

,0'1 Physical Plant

0 Care and Supervision

0 Personal Rights

0 Food Service 0 Qualifications 0 Other

)eficier:_cy Description To Be Corrected By Date

~---~ /t:.fA ,_ {J l/(_,,r/?} r{ __ /--//(/rJ__,./{ (/J)-?. t-/1&/oc;· (j I I I

JPERVISOR'S NAME TELEPHONE

,Af,fot;eJ) 5/0 (_(} Z--Z- 2-&- o 2... :ENSING ~ATOR NAME , TELEPHONE If 5. ee:.>c;U :ENSING EVALUATOR SIGI'jA'Fi!RE

DATE ~/ I ~ !_d. ,/ .-?' G).-; b /V DCJ ~ I!;'!/(. -.) /\_ ·----·---I

lave read and understand the electronic version of the full licensing report completed today at this facility. I acknowledge ceipt of this form and understand my appeal rights as explained on the back of this form. If "A" violations are cited, child tre providers must post this rep6·ry9;ending receipt of final report.

:ILITY REPRESENTATIVE SIGNATURE ~-'_"-----;r r ~ 1 DATE /

11 0 1·0

cr '-, ;, .. , !9 I

- ' . ,1 ~' / \'"-7--:::7'- ., \

FOR LPA USE yJ;5N PROVIDING A PRINTED COPY OF THE ELECTRONIC REPORT TO THE LICENSEE:


on ~~~


095 (8104)

(\

STATE OF CALIFORNIA • HEALTH AND HUMAN SERVICES AGENCY


FACILITY NAME: HEARTS LEAP ICRI PRESCHOOL ADMINISTRATOR: MASH HOUR, ELLIE ADDRESS: 2638 COLLEGE AVENUE CITY: BERKELEY CAPACITY: 70 TYPE OF VISIT: Annual/Random MET WITH: Ellie Mashhour


NARRATIVE

('


BARO·Child Care, 1515 ClaySt#1102 Oakland, CA 94612


013416236 850

(510) 549-1422 94704

06/24/2008 12:00 PM 03:30PM

1 An unannounced Annual/Random site visit was conducted by LPA Susan Neeson. Met initially with Tera 2 Tellock and, shortly, Ellie Mashhour. 3 4 All staff are fingerprint clear, most have current CPR and First Aid certification. 5 6 Toured the facility indoors and out. Reviewed a sample of staff records. Reviewed sign-in/out sheets. 7 Reviewed snack menus. Discussed sanitation procedures. 8 9 LJC 311 A was issued and discussed. Posting of required forms was discussed. LPA will send a copy of the 10 current car seat form and laminated immunization schedule to facility. 11 12 LPA observed nap time. 13 14 Facility was in ratio throughout the site visit. There are sufficient toys and equipment for children in care. 15 16 Deficiencies are on LIC 809 D. 17 18 Appeal Rights were discussed. 19 20 An exit interview was given 21 22 23 24 25




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TELEPHONE: (510)622-2646

TELEPHONE: (510)622-2625

DATE: 06/24/2008



~-~ DATE: 06/24/2008


LIC809 (FAS) • (06/04) Page: 1 of3

0



FACILITY NAME: HEARTS LEAP ICRI PRESCHOOL DEFICIENCY INFORMATION FOR THIS PAGE:


1 Personal Rights Type A 2 1. LPA observed a trash can in the Cypress

0612512008 3 classroom, which is only about two feet high.

Section Cited 4 Inside the can were dirty diapers accessible to 5 children.

101223 6 7

1 Drinking water Type A 2 2. There was no drinking water on the large yard fo

0612512008 3 use by the children.

Section Cited 4 5

101239.1 6 7

1 Buildings and Grounds Type A 2 3. LPA observed broken water table stand

0612512008 3 aluminum rods and other hazards accessible to

Section Cited 4 children on the play yard. 5

101238 c 6 7

1 Sign-in/out

Type A 2 4. LPA reviewed sign-in/out sheets for today and

0613012008 3 the last week. 3 children were not signed in today.

Section Cited 4 Over the last week, 10 children were not signed 5 out. One child was signed in by someone

101229.1 a 1 b 6 authorized by the parent. Several children were 7 signed with first name only.

0


BARO-Child Care, 1515 Clay St #1102 Oakland, CA 94612



1 Corrected during visit. 2 3 4 5 6 7



1 Ellie Mash hour states that she will have a system 2 in place to assure compliance by 6/30/08. 3 4 5 6 7





25ul~ V\)~

TELEPHONE: (510) 622-2646

TELEPHONE: (510)622-2625

DATE: 06/24/2008



~-~

This Notice must be posted for 30 days

LIC809 (FAS) • (06/04)

DATE: 06/24/2008

Page: 3 of3

'·

(\



FACILITY NAME: HEARTS LEAP JCRI PRESCHOOL DEFICIENCY INFORMATION FOR THIS PAGE:


1 Outdoor Activity Space Type B 2 5. LPA observed the sand under the climbing

06/30/2008 3 structure to be insufficient to protect children from

Section Cited 4 falls in several places. 5

101238.2 e 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

('.





1 Ellie Mash hour stated that this would be corrected 2 by 6/30/08. 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

Failure to correct the cited deficiency{ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.




~f\J~

TELEPHONE: (51 0)622-2646

TELEPHONE: (510)622-2625

DATE: 06/24/2008



~~ DATE: 06/24/2008

LIC809 (FAS)- (06/04) Page: 2 of3

FACILITY VISIT SUMMARY REPORT

= __ = ... ~.= .... ~.-==============~~ Complaint Control N~.-Qer:

ADDRESS

Complaint

D Prelicensing

D Management

L-eltfJ

~Random D POC

D Required

f4((e . '~

DEFICIENCY/CIVIL PENALTY INFORMATION

W Type A 0 Civil Penalty Assessed

~ Type B 0 Penalty Notice Given

D No Deficiency Cited 0 Penalty Cleared


D Limits of License

D Criminal Record

~ Records

D Food Service

Deficiency Description

5 ciCENSING EVAQJATOR NAME

~ Mt5tJN JCs;;~;:R SIGM 'E~

0 Program/Operation

0 Health Related/Medical Services

1:3' Physical Plant

0 Qualifications

~~~======r,F~AC~IL~IT~Y=~=P=E=========

CENSUS

&o TIME BEGAN

Announced /_:z&Z-0

TIME COMPLETED

~ Unannounced /530




0 Staffing/Ratio

0 Care and Supervision

~ Personal Rights

~ To Be Corrected By Date

0~

G zz-z_c; oz. l {

have read and understand the electronic version of the full licensing report completed today at this facility. I acknowledge eceipt of this form and understand my appeal rights as explained on the back of this form. If "A" violations are cited, child :are providers must post this report pending receipt of final report. ACILI~ R,EJ'flESENTATlVE SIG

(. •7 .-··~

DATE

6/zt.f/o[l

FOR LPA USE WHEN PROVIDING A PRINTED COPY OF THE ELECTRONIC'REPORT TO THE LICENSEE:


on (Date)


: 8098 (8/04) PAGE 1 OF 2

0



FACILITY NAME: HEARTS LEAP ICRI PRESCHOOL ADMINISTRATOR: HARDIMAN, JACKIE ADDRESS: 2638 COLLEGE AVENUE CITY: BERKELEY CAPACITY: 70 TYPE OF VISIT: Required- 5 Year MET WITH: Ellie Mashhour


NARRATIVE

f\




013416236 850

(510) 549-1422 94704

03/01/2007 02:20PM 04:20PM

1 LPA Susan Neeson conducted a required 5-year site visit. Met with Ellie Mashhour. Toured the facility inside. 2 Toured the yard. Inspected bathrooms. Reviewed sign-in/out sheets. Ratios were met during visit. Food 3 service snack was observed. Correct record keeping for snacks was discussed. A sample of children's 4 records were reviewed. 5 6 Deficiencies are cited on LIC 809 D. 7 8 An exit interview was given. 9 10 Appeal Rights were discussed. 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25




~N~

TELEPHONE: (510)622-2646

TELEPHONE: (510)622-2625

DATE: 03/01/2007



DATE: 03/01/2007


LIC809 (FAS) - (06/04) Page: 1 of2

(\






1 1. LPA reviewed sign-in/out sheets from 2/28/2007. Type A 2 Two children were not signed-out. One child was

03/01/2007 3 not signed-in, seven were signed with first name

Section Cited 4 only and many were signed with initials or illegible 5 scrawls.

101229.1 6 7

1 2. There is no one present with proof of current Type A 2 CPR and First Aid certification.

3 03/01/2007 4

Section Cited 5 101215.1 m 6

7

1 3. Fence in yard which has white lattice work is not Type A 2 4 feet high. Fence in 2's yard has a hole in it with

03/01/2007 3 splinters and a protruding nail. 4

Section Cited 5 101238 a 6

7

1 2 3 4 5 6 7

- - - -~~ ---- - - ---

(-'\


BARO·Child Care, 1515 Clay St #11 02 Oakland, CA 94612


PLAN OF CORRECTIONS(POCs}

1 Correct by March 2, 2007. 2 3 4 5 6 7

1 Correct by April 1, 2007 and maintain at all times. 2 3 4 5 6 7

1 Correct by 5 March 2007. 2 3 4 5 6 7

1 2 3 4 5 6 7





St~Af~

TELEPHONE: (51 0)622-2646

TELEPHONE: (510}622-2625

DATE: 03/01/2007



DATE: 03/01/2007

This Notice must be posted for 30 days

LIC809 (FAS) • (06/04) Page: 2 of2

0 r STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGl CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CIVIL PENALTY LEDGER PAYMENT, REDUCTION, OR WAIVER RECORD

INVOICE NQ._0_2o_1_43_5 _________ _ DISTRICT OFFICE NUMBER_o2 __ _

·' FACILITY NAME

~-FISCAL YEAR DATE LIC 422 SENT

INTERNATIONAL CHILD RESOURCE INSTITUTE 2005/2006 3/1/06 FACILITY ADDRESS FACILITY TYPE FACILITY PCA CODE

2938 COLLEGE AVE CCC 850 CITY STATE ZIP CODE

BERKELEY CA 94704

LICENSEE(S) I FACILITY NUMBER

INTERNATIONAL CHILD RESOURCE INSTITUTE 013416236 ADDRESS

2938 COLLEGE AVE CITY STATE ZIP CODE

BERKELEY CA 94704

DATE AMOUNT CUMULATIVE BALANCE Original Invoice Amount

3/1/06 $800.00

Civil Penalty Waiver $0.00

Penalty Review Reduction

Penalty Review Reduction

Payment 1

4\ I~) O(o wo- 8 Payment 2

Payment 3

Payment 4

Payment 5

BALANCE

COMMENTS:

LIC 422A (5/01)

I

f'·, {'


/ CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

NOTICE OF CIVIL PENALTIES DUE

INVOICE NO. 0201435

l Initial Invoice W Final Notice

DISTRIC~ COUNTY OFFICENUMBER_02 ___ _

FACILITY NAME

INTERNATIONAL CHILD RESOURCE INSTITUTE FISCAL YEAR

··"r~ DATE LIC 422 SENT

2005/2006 " 3/1 FACILITY ADDRESS FACILITY TYPE .;

..... PENALTY PCA CODE


BERKELEY CA 94704

[

FACILITY NUMBER

013416236

I LICENSEE(S) OR UNLICENSED FACILITY OPERATOR

INTERNATIONAL CHILD RESOURCE INSTITUTE ADDRESS DATE

2638 COLLEGE AVE 3/1/06 CITY STATE ZIP CODE

BERKELEY CA 94704 RICHARD TERAN, LUM

fhe California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition )f civil penalties against any facility which fails to take corrective action within prescribed time periods.

fhe California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for he imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time Jeriods.

-he California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the nposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background equirements. ·

our facility has been found in violation of Community Care Licensing statutes and regulations .

. failure to correct the immediate Civil Penalty or deficiency(ies) cited on the Licensing Report (LIC 809 or L!C 9099)

ated 10/24/05 has resulted in the following civil penalty assessment of:

enalty Amount Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $800.00

;,ss Payment(s) Received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $0.00

ALANCE DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $800.00

,... ......... ~1.-..- ---1--- _, --- ~--- ----

AMOUNT EXPLANATION

3189 MAGIC YEARS COOPERATIVE

1221 NEVIN AVENUE, SUITE 200 RICHMOND, CA 94802

(§THE MECHANICS BANK NORTHERN CALIFoRNIA'S MoST TRUSTED BANK. SniCE 1905.~

1-800-797-6324

n•oo ~ •a gn•~,. (,..-

DESCRIPTION

DOLLARS

CHECK NUMBER

3;8

£14o,- ,J{)i --\

90·203-1211

CHECK AMOUNT

$gOo.-a. ~eat~ l!J Oelllbon&ck.

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DEPARTMENT OF SOCIAL SERVICES COMMUNIITY CARE LICENSING 1515 Clay Street, Suite 11 02 Oakland, California 94612 Telephone: (51 0) 622-2602

Date: o/27/2-t9-e &

To: /1&:-./-ft ~e~ ~C£/ Pre"Sdt!U< 2 & s g-~ ,4--r,P-;4Ud'-

g~~e:&{JI C/l 9~70 V

' Re: L?~ #:: &r35//& 23~

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SUBJECT: FORFEITURE OF LICENSE/CLOSURE OF FILE

ARNOLD SCHWARZENEGGER, Governor

The license of the above facility is forfeited pursuant to Health and Safety Code Section 1596.858 (forfeiture of license by operation of law), effective ....h~ I' z /2&?-& ~

The reason for the forfeiture is: 1. [ ] Licensee has sold or transferred the facility. Child Care Centers Only) 2. [ ] Licensee has moved. 3. [ ] Licensee has died. 4. [ ] Licensee has abandoned the facility.

a. [ ] telephone is disconnected. 5. [ ] The Licensee is convicted of an offense specified in section 220, 243.4

or 254.1 of paragraph (1) of section 273a, section 273d, 228 or 289 of the Penal Code or is convicted of another crime specified in subdivision © of the Section 667.5 of the Penal Code.

6. [ ] Licensee has surrendered the license to the Departmen( _, 7. [ ] Licensee is no longer interested in maintaining a license and no longer

cares for children. 8. ~.Non payment of fees.

Please be advised that once your license is forfeited or closed, all provisions of care and supervision must cease. If you have not done so already, please send your license to the above address. If you wish to operate a children's day care facility again you need to reapply and be approved for a new license.

If you have any questions about this action, please call (51 0) 622-2625 or write the above address.

Sincerely,

3zt.9hc Jtfff~~ Susan Neeson Licensing Program Analyst

- i~ !-

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

FACILITY EVALUATION REPORT BARO-Child Care, 1515 Clay St.,# 1102 Oakland, CA 94612

FACILITY NAME:

HEARTSLEAPICRIPRESCHOOL FACILITY NUMBER: 013416236

DIRECTOR: HARDIMAN, JACKIE 2638 COLLEGE AVENUE

FACILITY TYPE: 850 (510) 549-1422

94704 ADDRESS: TELEPHONE: CITY: BERKELEY STATE:CA ZIP CODE:

CAPACITY: 70 CENSUS: DATE: 01/09/2006 10:00 AM 10:45 AM

TYPE OF VI.SIT: UNANNOUNCED TIME BEGAN: MET WITH: TIME COMPLETED:

DEFICIENCY INFORMATION FOR THIS PAGE: CIVIL PENALTY INFORMATION: No Deficiency Cited Not Applicable

1 2 3 4 5

January 11, 2006

Dear Ms. Mashhour:

COMMENTS/DEFICIENCIES

~ An Informal Conference was held on January 9, 2006, in the District Office listed 8 above. You were present with Susan Neeson, Licensing Program Analyst, and

190

myself. This meeting was scheduled to discuss a complaint substantiated against 11 the facility on October 24, 2005, and your letter of appeal dated December 12, 12 2005. 13 14 15 16 17 18 19 20 21 22 23

The complaint alleged:

1) A Personal Rights violation: Children do not have access to play yard. 2) A Physical Plant violation: Scaffolding made the play yard inaccessible. 3) A Record Keeping violation: The facility failed to inform the agency of construction or physical plant changes.

All three allegations were substantiated and the facility was properly cited.

We discussed the complaint issues and how a provisional outdoor activity plan should have been submitted as an alternative for the children during the construction. You replied that a near-by park was used for activities during the construction; with knowledge and consent of the parents.

At the time of her visit, Ms. Neeson noted how construction material had fallen from the roof into the yard. This material may have presented a danger to children and we discussed how the facility failed to secure the area from children and provide a safe environment.

A case management review of the facility was conducted on the same date that resulted in the citation of eight additional deficiencies and a Civil Penalty

.,..... 0 r,

assessment of $800.00. These. deficiencies included, but are not limited to, the following Type "A" violations:

1) Section 101170: Criminal Record Clearance 2) Section 101229: Responsibility for Providing Care and Supervision 3) Section 101212 (b): Reporting Requirements

In the appeal letter dated December 12, 2005, you requested consideration for the Civil Penalties of $800.00 issued for Section 101170: Criminal Record Clearance; failure to obtain clearance for nine teachers. Wendy Johnson was previously employed with the licensee, so while included in the citation there were no civil penalties for failure to associate her fingerprints, but the facility received a $100.00 penalty for each of the other eight staff for a total of $800.00.

The appeal letter states that you called the licensing office (prior to the 1 0/24/05 visit) and that all nine teachers were in the system and you put their clearance numbers in their files without submitting the request for association. Unfortunately, this proved to be a false statement, as one of the teachers, Sara Christine Prince, did not submit her prints until 10/28/05 and another, Karen Jackson, has yet to do so as of this date. Ms. Neeson could have assessed up to $500.00 for each staff person that was not associated for a total of $4000.00. In light of the intentionally misleading appeal letter I am inclined to double the assessment for $800.00 to $1600.00. The Licensing Report will be re-written to reflect this change. In the case of Ms. Jackson, who has yet to submit fingerprints, the facility could be assessed up to $3000.00 if she returns to work without clearance.

We discussed how the regulations regarding Criminal Record Clearance for all staff is really the first and most formidable line of defense to insure the health and safety of children in out of home care. It is a crucial regulation that all facilities must follow. The requirements for fingerprinting staff have changed through the years. A number of terrible incidents years ago prompted the requirement to have staff cleared before they start working. To encourage compliance, the civil penalties were recently increased to their present level.

The recent citations and the details of the appeal indicate a lack of knowledge of the procedures and licensing regulations that a Director of a child care center should know. To assist you with this, you have agreed to attend a Component 3 orientation, which are held every third Thursday of the month here in our building. The next orientation will be on January 19, 2006, from 9:30A.M. to 1:00 P.M., on the second floor in room# 12, here in the State building.

It is important that your facility is compliant with regulations to avoid future citations and Civil Penalties. To facilitate this, I suggested open and clear communications with the licensing agency. You were advised to call Ms. Neeson with any questions regarding regulations or policy.

'-..,

0 ~ I

You were also advised that in the absence of Ms. Neeson, you and your staff can call the "desk duty officer", whose job for the day is to answer questions and take incident reports from licensed providers. Should either of these resources be unavailable, you are then encouraged to call me.

Ms. Neeson, the desk duty officer, and I can all be reached at (51 0) 622-2602.

Sincerely

Richard J. Teran Licensing Program Manager


SUPERVISOR'S NAME: Fred Gill

LICENSING EVALUATOR NAME: Richard Teran

LICENSING EVALUATOR SIGNATURE: ___________ _

TELEPHONE: 510-622-2602

TELEPHONE: 510-622-2602

DATE: 01/09/2006


FACILITY REPRESENTATIVE SIGNATURE: __________ _ DATE: 01/09/2006

LIC809 (FAS) • (06/04) Page: 1 of 1

0 STATE OF CALIFORNIA- HEALTH AND HUM. .:RVICES AGENCY

DEPARTMENT OF SOCIAL SERVICES COMMUNIITY CARE LICENSING 1515 Clay Street, Suite 1102 Oakland, California 94612 Telephone: (510) 622-2602

January 11 , 2006

Ellie Mashhour Hearts Leap School 2638 College Ave. Berkeley, CA 94704

Dear Ms. Mashhour:

0 _ . .RNOLD SCHWARZENEGGER, Governor

License # 013416236

An Informal Conference was held on January 9, 2006, in the District Office listed above. You were present with Susan Neeson, Licensing Program Analyst, and myself. This meeting was scheduled to discuss a complaint substantiated against the facility on October 24, 2005, and your letter of appeal dated December 12, 2005.

The complaint alleged:

1) A Personal Rights violation: Children do not have access to play yard. 2) A Physical Plant violation: Scaffolding made the play yard inaccessible. 3) A Record Keeping violation: The facility failed to inform the agency of construction or

physical plant changes.

All three allegations were substantiated and the facility was properly cited.

We discussed the complaint issues and how a provisional outdoor activity plan should have been submitted as an alternative for the children during the construction. You replied that a near-by park was used for activities during the construction; with knowledge and consent of the parents.

At the time of her visit, Ms. Neeson noted how construction material had fallen from the roof into the yard. This material may have presented a danger to children and we discussed how the facility failed to secure the area from children and provide a safe environment.

" A case management review of the facility was conducted on the same date that resulted in the citation of eight additional deficiencies and a Civil Penalty assessment of $800.00. These deficiencies included, but are not limited to, the following Type "N' violations:

1) Section 1 01170: Criminal Record Clearance 2) Section 101229: Responsibility for Providing Care and Supervision 3) Section 101212 (b): Reporting Requirements

('

Ellie Mashhour Hearts Leap School letter page 2. January 1 0, 2006

('

In the appeal letter dated December 12, 2005, you requested consideration for the Civil Penalties of $800.00 issued for Section 101170: Criminal Record Clearance; failure to obtain clearance for nine teachers. Wendy Johnson was previously employed with the licensee, so while included in the citation there were no civil penalties for failure to associate her fingerprints, but the facility received a $100.00 penalty for each of the other eight staff for a total of $800.00.

The appeal letter states that you called the licensing office (prior to the 10/24/05 visit) and that all nine teachers were in the system and you put their clearance numbers in their files without submitting the request for association. Unfortunately, this proved to be a false statement, as one of the teachers, Sara Christine Prince, did not submit her prints until 1 0/28/05 and another, Karen Jackson, has yet to do so as of this date.

Ms. Neeson could have assessed up to $500.00 for each staff person that was not associated for a total of $4000.00. In light of the intentionally misleading appeal letter I am inclined to double the assessment for $800.00 to $1600.00. The Licensing Report will be rewritten to reflect this change. In the case of Ms. Jackson, who has yet to submit fingerprints, the facility could be assessed up to $3000.00 if she returns to work without clearance.

We discussed how the regulations regarding Criminal Record Clearance for all staff is really the first and most formidable line of defense to insure the health and safety of children in out of home care. It is a crucial regulation that all facilities must follow. The requirements for fingerprinting staff have changed through the years. A number of terrible incidents years ago prompted the requirement to have staff cleared before they start working. To encourage compliance, the civil penalties were recently increased to their present level.

The recent citations and the details of the appeal indicate a lack of knowledge of the procedures and licensing regulations that a Director of a child care center should know. To assist you with this, you have agreed to attend a Component 3 orientation, which are held every third Thursday of the month here in our building. The next orientation will be on January 19,2006, from 9:30A.M. to 1:00 P.M., on the second floor in room# 12, here in the State building.

It is important that your facility is compliant with regulations to avoid future citations and Civil Penalties. To facilitate this, I suggested open and clear communications with the licensing agency. You were advised to call Ms. Neeson with any questions regarding regulations or policy.

You were also advised that in the absence of Ms. Neeson, you and your staff can call the "desk duty officer", whose job for the day is to answer questions and take incident reports from licensed providers. Should either of these resources be unavailable, you are then encouraged to call me.

..:.;..

,~ 0 Ellie Mashhour Hearts Leap School letter page 3. January 10, 2006

('

Ms. Neeson, the desk duty officer, and I can all be reached at (510) 622-2602.

Sincerely

Licensing Program Manager

Attachment: Revised licensing report: Please sign a copy and return.

-· ('




Deficiency Type DEFICIENCIES POC Due Date I Section Number

Type A 1 1. Eight Staff are not associated with this facility. 10/24/2005 2

Section Cited 3

101170 Criminal 4 5

Record Clearance 6 7

Type A 1 2. Dance teacher, Karen Jackson, was observed supervising 10/24/2005 2 12 children for dance class. Another teacher was not present.

Section Cited 3 She is not fingerprinted.

101229 4 Responsibility for 5

providing care and 6

supervision 7

Type A 1 3. Sixty children are present. One was not signed-in. 10/24/2005 2 Thirty-five were signed-in with initials, first name only, or, in

Section Cited 3 one case "me". Full signature and time is required.

101229.1 4 5

Sign-in/out 6 7

('


BARO-Child Care, 1515 Clay St #11 02 Oakland, CA 94612

VISIT DATE: 10/24/2005


1 Correct by 10/25/05. A Civil Penalty of 2 $1600 amended after the Informal 3 Conference 1/9/2006. 4 5 Amended date for this citation is 6 1/11/2006. 7

1 Correct by 10/25/05. 2 3 4 5 6 7

1 Correct by 10/25/05 and maintain at all 2 times. 3 4 5 6 7

I

Type A 1 4. Twenty napping children lacked sheet to cover mat. 1 Correct by 10/25/05 and maintain at all i 10/24/2005 2 2 times.

Section Cited 3 3

101239.1 (c) 4 4 5 5

Napping equipment 5 6 7 7


SUPERVISOR'S NAME: Richard Teran


LICENSING EVALUATOR SIGNATURE:. ___________ _

TELEPHONE: (510)622-2648

TELEPHONE: (510)622-2625

DATE: 11/02/2005


FACILITY REPRESENTATIVE SIGNATURE:. __________ _ DATE: 11/02/2005

LIC809 (FAS) • (06/04) Page: 2 of 3

(', 0

December 12, 2005

To Licensing Program Supervisor,

""<.: ~ ... -~~- ~~~ :·u ). ' ,-·, r"• \.-:.:

""'"(?:·· ~; ... , . .

We had an unannounced visit of our facility on Oct. 19, 2005. (Facility Number 013416236) All the staff fills were reviewed and $800.00 Civil Penalty was issued. As a new director at this facility, I called Licensing Division and asked for clearance number by providing the staff's full name or their Social security number. All teachers ware in the system, I simply put their clearance number on their file and did not associate the staff with our facility. Susan Neeson, the Licensing program analyst, advised me the importance of associating the staff to the facility and I immediately took care of the issue. I am hoping by writing to you and explaining our situation you will kindly consider to waive the penalty which that would help our school in this time. I hope that I was clear with my explanation, but if you need more information , or any question you may have, please call me at (510) 549-1422.

S~erely, !d" 1.}~ --~-;(!l..J .. t:Iv

~llie Mashhour Hearts Leap School

(' r-', I

yjl021L· STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

~

NOTICE OF CIVIL PENALTIES DUE

1121 Initial Invoice 0 Final Notice

INVOICE NO. 0201435 DISTRICT OR COUNTY OFFICE NUMBER_o2 ___ _

FACILITY NAME FISCAL YEAR DATE LIC 422 SENT

INTERNATIONAL CHILD RESOURCE INSTITUTE 2005/2006 3/1 FACILITY ADDRESS FACILITY TYPE PENALTY PCA CODE


BERKELEY CA 94704 FACILITY NUMBER

LICENSEE(S) OR UNLICENSED FACILITY OPERATOR 013416236

INTERNATIONAL CHILD RESOURCE INSTITUTE ADDRESS

2638 COLLEGE AVE CITY STATE ZIP CODE

BERKELEY CA 94704

The California Health and Safety Code, Sections 1548, 1568.0822, 1569.49, 1596.99, and 1597.62 provides for the imposition of civil penalties against any facility which fails to take corrective action within prescribed time periods.

The California Health and Safety Code, Sections 1547, 1568.0821, 1569.485, 1596.89, 1596.891 and 1597.61 provides for the imposition of civil penalties against any unlicensed facility which fails to take corrective action within prescribed time periods.

The California Health and Safety Code, Sections 1522, 1568.09, 1569.17, 1596.871, and 1596.8712 provides for the imposition of immediate civil penalties against any facility which fails to comply with fingerprinting or other criminal background requirements.

Your facility has been found in violation of Community Care Licensing statutes and regulations.

A failure to correct the immediate Civil Penalty or deficiency(ies) cited on the Licensing Report (LIC 809 or LIC 9099)

dated 1 0/24/05 has resulted in the following civil penalty assessment of:

Penalty Amount Due . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $800.00

Less Payment(s) Received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $0.00

BALANCE DUE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $800.00

Send the enclosed copy of this notice and your payment to the address shown below within 1 0 days. MAKE CHECKS PAYABLE TO THE CALIFORNIA DEPARTMENT OF SOCIAL SERVICES. Please write your invoice and facility number(s) on your check.

CDSS, COMMUNITY CARE LICENSING

ATTN: CIVIL PENALTY CLERK

1515 CLAY STREET, SUITE 1102

OAKLAND CA 94612-1469

FAILURE TO PAY CIVIL PENALTY MAY RESULT IN ANY OR ALL OF THE FOLLOWING:

• SMALL CLAIMS COURT ACTION

• LICENSE DENIAL, SUSPENSION, OR REVOCATION

• SEIZURE OF PERSONAL INCOME TAX REFUNDS LIC 422 (1 0/03) (PUBLIC)

", /};YJ/!'~1', CIVIL PK T},LTIES COJ'vfPUTATION

OQ..C; l ?~(c6' O~O\lf3_~

LICENSEE: //7/lCl(_/1/AT?tJN'/1- L cfi;LIJ RcStxv!CCC3 /NS77Tlvle

FACILITY NAME: /-/ e?l1e- 7> L. e7-1-;:? / C ,e ( ~1tut? mt / R c/S vYtf-& G

FACILITY ADDRESS: 262??: ~~

befldeg /Of 9tt7o Y FACILITY NUMBER: f) ( 3C((& ?-,3 ~ SSN/CORP # · -

Tfl r- r IJ t:I qqz'65s o 1 'i?

* Date of visit report citing deficiency: /CJ /z__ w~ s;-* Date civil penalty begins: / qiZ. G/(~ ~

C<912 f? -tf;::: It) '? s {) (/ ~

(i=or non-immediate penalties, this is the dayfoUowing Jhe date ihe deficiency was due to be corrected.) l .

~ Date civil penalty stops: . ~/ -r/ ~ - -(This is the day the deficiency is corrected', the day the licensee notifies us that it is corrected unless we visit within 5 days and determine otherwise or the 30th calendar day of penalties if the deficiency has not been corrected.)

0 Amount of the first daV1S civil penalty:

[ J $50 [ J $150 (IMMEDIAE CP) [ J $200 (UNLICENSED CP) = $

f>d\ $..~ (IMMEDIATE i=ING:::RPRINT CP) X s (INDIVIDUALS) ~ r - J

flo~~ (V

@ Pi U;:, amount of subsecn.!ent daily civil penalties:

~~ t/l(o0'() DY

·""'

[ ] $50 (REG. & IMM. CP) [ J $150 (2ND IMM. CP) [ J $200 (UNLIC:::NS:::D CP)

-~ multiply by# of days* ____ _ = $ __ _

* (count from the day after the cp started throuah the day the cp stopped) @.-()

el Fqua!s the total amount of civil penalties: = $ ?S&P~;c

LPA: ~ih{_ M~~ DATE: /V /z f( Z-61-Dg:-1

LPS: ///C//_ /..:'A>.. DATE: I I· /)' 0 j

A.. ' ... . • d . h .. 6/ -~ z.. d -e.z~. "h .. , I ;I··. ) lb, .,c..,! 0 A"' b'll' th ."'.:-:s.:~ t'::2 s1gne rorm tot e case"i!le an routelV11 e CIVI pena ty c erK ror 1 1ng. ner 1 1ng, e case file will be returned to the LPA or the LPS for revie

DATE PROCESSED: "--3 \I\ 0 V ov. '-' I . "-!... ( ,I'-..-'"'----"""\...../ :3,

(BAD033 2/98)

r-



FACILITY NAME: DIRECTOR: ADDRESS: CITY:

HEARTS LEAP ICRI PRESCHOOL

HARDIMAN, JACKIE 2638 COLLEGE AVENUE BERKELEY

CAPACITY: 70 TYPE OF VISIT: Case Management MET WITH: Ellie Mashhour

DEFICIENCY INFORMATION FOR THIS PAGE: Type A

(-


BARO·Chlld Care, 1515 Clay St#1102 Oakland, CA 94612

FACILITY NUMBER:

FACILITY TYPE: TELEPHONE:

STATE:CA ZIP CODE:

CENSUS: 60 DATE: UNANNOUNCED TIME BEGAN:

TIME COMPLETED:

CIVIL PENALTY INFORMATION: Penalty Assessed

013416236

850 (510) 549-1422

94704

10/24/2005 11:45 AM 02:30PM


1 In the course of a complaint site visit, a case management visit was also done. Staff files were reviewed. The 2 inside of the facility was toured. Sign-in/out sheets were reviewed. Nap time was observed. 3 4 According to California Code of Regulations, Title XXII, the following deficiencies are observed: 5 6 Citations are on 809 D. 7 8 LIC 311 A was issued and discussed. 9 1 0 An exit interview was given. Appeal Rights were discussed. 11 12 It is strongly suggested that cubbies for children's belongings be installed such that the clothing and/or 13 bedding of one child do not touch the clothing/bedding of other children. 14 15 16 17 18 19 20 21 22 23





TELEPHONE: (510)622-2648

TELEPHONE: (510)622-2625

DATE: 1 0/24/2005


FACILITY REPRESENTATIVE SIGNATURE:. __________ _ DATE: 10/24/2005

LIC809 (FAS) • (06/04) Page: 1 of 3

('






Section Cited 3

101170 Criminal 4 5

Record Clearance 6 7



101229 4

Responsibility for 5


supervision 7


Section Cited 3 one case "me". Full signature and time is required. 4

101229.1 5 Sign-in/out 6

7

Type A 1 4. Twenty napping children lacked sheet to cover mat.

10/24/2005 2

Section Cited 3 4

101239.1 (c) 5 Napping equipment 6

7

('



VISIT DATE: 1 0/24/2005


1 Correct by 10/25/05. A Civil Penalty of . 2 $1600 amended after the Informal !

3 Conference 1/9/2006. 4 5 Amended date for this citation is 6 1/11/2006. 7

1 Correct by 10/25/05. 2 3 4 5 6 7







TELEPHONE: (51 0)622-2648

TELEPHONE: (51 0)622-2625

DATE: 11/02/2005



LIC809 (FAS) - (06/04) Page: 2 of3

!"





Type A 1 5. Ellie Mash hour took over as Director in Sept. 2005. Her 10/24/2005 2 appointment and documents were not submitted in 1 0 days

Section Cited 3 as required.

101212 (b) 4 5

Reporting 6 Requirements 7

Type A 1 6. LPA reviewed staff records. Six lack Dr. exam. Foru lack 10/24/2005 2 TB test results.

Section Cited 3 4

101217 (a) (12) (13) 5 (b) (10) Personnel 6

Records 7

Type A 1 7. LPA reviewed staff records. Six lacked proof of 10/24/2005 2 educaitonal qualifications.

Section Cited 3 4

101216.1 TEacher 5 Qualifications 6

7

Type A 1 8. Annual License fee has not been paid. 10/24/2005 2

Section Cited 3 4

101187 (a) 5 Application/Annual 6

Fee 7

0


BARO·Child Care, 1515 Clay St #1102 Oakland, CA 94612



1 2

Correct by 10/31/05.

3 4 5 6 7

1 2


3 4 5 6 7

1 Correct by 11/25/05. 2 3 4 5 6 7

1 2


3 4 5 6 7

_L___ ___ ~_





TELEPHONE: (510)622-2648

TELEPHONE: (510)622-2625

DATE: 11/02/2005



LIC809 (FAS) • (06/04) Page: 3 of 3

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION

CIVIL PENALTY ASSESSMENT (Unlicensed and Criminal Background)


FACILITY NAME DATE

HEARTSLEAPICRIPRESCHOOL 10/24/2005 FACILITY ADDRESS CITY

2638 COLLEGE AVENUE BERKELEY STATE ZIP CODE

CA 94704 LICENSEE{S)/OPERATOR FACILITY NUMBER

INTERNATIONAL CHILD RESOURCE INSTITUTE 013416236

UNLICENSED FACILITY Civil penalties can be assessed against any unlicensed facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1547, 1568.03, 1568.0821, 1569.48, and 1598.891. You are hereby notified that a civil penalty has been assessed. Your facility has been found operating without a license. This is in violation of the California Health and Safety Code Sections 1508, 1568.03, 1569.10, or 1596.80. A Notice of Operation in Violation of Law or Denial of Application was issued on giving notice that failure to submit a completed application or cease operation could result in a civil penalty. 0 Because you failed to file a completed application or cease operation, a civil penalty of $0.00 is assessed for the period from

through .

0 Residential Care Facility for the Elderly (RCFE): Since a completed application was not submitted by the 15th day, on day 16 from date of notice or letter, $100 per resident per day is being assessed retroactively. From day 16, $200 per resident per day is being assessed until a completed application is submitted or operations cease (if you have not had a previous application denied).

0 Residential Care Facility for the Chronically Ill (RCF-CI): An immediate civil penalty of $100 per resident per day is being assessed. If a completed application is not submitted by the 15th day, on day 16 from date of notice or letter, $200 per resident per day is being assessed until a completed application is submitted or operations cease (if you have not had a previous application denied).

0 Child Care Center, Family Child Care Home, Community Care Facility: since a completed application was not submitted by the 15th day, on day 16 from the date of notice or letter, $200 per day is being assessed until a completed application is submitted or operations cease (if you have not had a previous application denied).

CRIMINAL BACKGROUND CLEARANCE (Immediate) Civil penalties can be assessed for failure to comply with the requirement for fingerprinting and other criminal background requirements, per California Health and Safety Code Sections 1522, 1568.09, 1569.17, 1596.871 and 1596.8712. You are hereby notified that a civil penalty has been assessed. A Facility Evaluation Report (LIC 809) was issued on 10/24/2005 giving notice that your facility has been found in violation of the fingerprinting criminal background clearance requirements.

l8J $100 Immediate Civil Penalty per person for failure to obtain a DOJ criminal record clearance or an exemption.

0

0

0

0

0

$100 Immediate Civil Penalty per person for failure to request that a previously cleared or exempted person be associated to the facility.

$100 immediate Civil Penalty per parent/authorized representative for failure to provide "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Exclusion)".

$100 immediate Civil Penalty per parent/authorized representative for failure to provide "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Reinstatement)".

$100 immediate Civil Penalty per parent/authorized representative for failure to obtain signature indicating receipt of Addendum.

$100 immediate Civil Penalty for failure to provide signed addendum to the Department when requested.

§. Number of Persons X $100 = $800.00 Total Penalty YOU WILL RECEIVE A BILL IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL!

NAME OF LICENSING PROGRAM ANALYST NAME OF FACILITY REPRESENTATIVEfTITLE

Susan Neeson Ellie Mashhour SIGNATURE OF LICENSING PROGRAM ANALYST SIGNATURE OF FACILITY REPRESENTATIVE

NAME OF DEPARTMENTAL REVIEWER AND TITLE fTITLE

Richard TEran Director 10/24/2005

LIC421A (FAS) • (10/03) Page: 1 of2


COMPLAINT INVESTIGATION REPORT


BARO-Child Care, 1515 ClaySt#1102 Oakland, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/19/2005 and conducted by Evaluator Susan Neeson

PUBLIC COMPLAINT CONTROL NUMBER: 02-CC-20051019162145

FACILITY HEARTS LEAP ICRI PRESCHOOL FACILITY NUMBER: 013416236 NAME: DIRECTOR: HARDIMAN, JACKIE FACILITY TYPE: 850 ADDRESS: 2638 COLLEGE AVENUE TELEPHONE: (510) 549-1422 CITY: BERKELEY STATE:CA ZIP CODE: 94704

CAPACITY: 70 CENSUS: 60 DATE: 10/24/2005 Complaint UNANNOUNCED TIME VISIT BEGAN: 11:45 AM

MET WITH: Ellie Mashhour TIME COMPLETED: 02:30PM

ALLEGATION(S): 1 Personal Rights- Children do not have access to play yard. 2 3 4 5 6 7 8 9

INVESTIGATION FINDINGS: 1 LPA toured the yards in the back of the building. Due to construction on the roof of the building, wood, naeil 2 and other construction items fall in the large yard leaving it too dangerous for children to play. 3 4 Cited on LIC 809 D. 5 6 7 8 9 10 11 12 13

Substantiated




Estimated Days of Completion:

TELEPHONE: (510)622-2648

TELEPHONE: (510)622-2625

DATE: 10/24/2005



LIC9099 (FAS) • (06/04) Page: 1 of2

Control Number 02-CC-20051019162145 STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)



Type A 1 1. LPA observed construction detritus in the play yard that 10/24/2005 2 makes the area unsafe for children.

Section Cited 3 4

101223 (a) (2) 5 Personal Rights 6

7

1

Section Cited 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7


BARO·Child Care, 1515 Clay St #1102 Oakland, CA 94612



1 2


3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7





TELEPHONE: (510)622-2648

TELEPHONE: (510)622-2625

DATE: 11/02/2005


FACILITY REPRESENTATIVE SIGNATURE:, __________ _ DATE: 11/02/2005

LIC9099 (FAS) • (06/04) Page: 2 of2




BARO·Child Care, 1515 Clay St #11 02 Oakland, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on 10/19/2005 and conducted by Evaluator Susan Neeson

COMPLAINT CONTROL NUMBER: 02-CC-20051019162145

FACILITY HEARTSLEAPICRIPRESCHOOL FACILITY NUMBER: 013416236 NAME: DIRECTOR: HARDIMAN, JACKIE FACILITY TYPE: 850 ADDRESS: 2638 COLLEGE AVENUE TELEPHONE: (510) 549-1422 CITY: BERKELEY STATE:CA ZIP CODE: 94704



ALLEGATION(S): 1 Physical Plant- There is scaffolding covering the building. This makes the play yard inaccessible. 2 3 4 5 6 7 8 9

INVESTIGATION FINDINGS: 1 LPA observed scaffolding on the half of the building next door (2640 College Avenue). This building is 2 attached to the building used for child care. Workers, however, are on both roofs. The larger of the play 3 grounds is located in the rear of 2640 College Avenue. Wood and other items from the roof work have fallen in 4 the play yard making it unsafe for children. According to Ellie Mashhour, the work has been ongoing since 5 Sept. 2005. 6 7 Citation on 809 D. 8 9 10 11 12 13

Substantiated





TELEPHONE: (510)622-2648

TELEPHONE: (51 0)622-2625

DATE: 10/24/2005



LIC9099 (FAS) • (06/04) Page: 1 of2

Control Number 02-CC-20051 019162145 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY




Type A 1 1. LPA observed items from roof work, such as pieces of 10/24/2005 2 wood and nails on the ground in the large play yard. This

Section Cited 3 yard is not to be used until construction is completed and it is 4 completely safe. 101238 (a) (b) (c) 5

Buildings & 6 Grounds 7

1 Section Cited 2

3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7


BARO-Child Care,1515 Clay St#1102 Oakland, CA 94612



1 2

Correct by 1 0/25/05.

3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7





TELEPHONE: (510)622-2648

TELEPHONE: (510)622-2625

DATE: 10/24/2005


FACILITY REPRESENTATIVE SIGNATURE:, __________ _ DATE: 10/24/2005

LIC9099 (FAS) - (06/04) Page: 2 of2




BARO-Chlld Care, 1515 Clay St #1102 Oakland, CA 94612

This is an official report of an unannounced visiUinvestigation of a complaint received in our office on 1 0/19/2005 and conducted by Evaluator Susan Neeson

PUBLIC COMPLAINT CONTROL NUMBER: 02-CC-20051019162145

FACILITY HEARTS LEAP ICRI PRESCHOOL FACILITY NUMBER: 013416236 NAME: DIRECTOR: HARDIMAN, JACKIE FACILITY TYPE: 850 ADDRESS: 2638 COLLEGE AVENUE TELEPHONE: (510) 549-1422 CITY: BERKELEY STATE:CA ZIP CODE: 94704



ALLEGATION(S): 1 Record Keeping - Center failed to inform CCL of physical plant changes. 2 3 4 5 6 7 8 9

INVESTIGATION FINDINGS: 1 LPA observed construction in progress at facility. Construction has been under way since Sept. '05. 2 Notification of alterations to existing buildings was not received. 3 4 5 Citation on 809 D. 6 7 8 9 10 11 12 13

Substantiated



LICENSING EVALUATOR SIGNATURE:, ____________ _


TELEPHONE: (510)622-2648

TELEPHONE: (510)622-2625

DATE: 10/24/2005


FACILITY REPRESENTATIVE SIGNATURE: __________ _ DATE: 1 0/24/2005

LIC9099 (FAS) - (06/04) Page: 1 of2

Control Number 02-CC-20051019162145 STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY




Type A 1 1. Facility is having roof work done at facility. The 10/24/2005 2 Department was not notified.

Section Cited 3 4

101237 (a) (b) (c) 5 Alterations to 6

existing buildings 7

1 Section Cited 2

3 4 5 6 7

1 2 3 4 5 6 7

-1 2 3 4 5 6 7


BARO-Child Care,1515 ClaySt#1102 Oakland, CA 94612



1 Correct by 10/25/05. Send copies of 2 permits and schedule showing when 3 work will be completed. 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7

1 2 3 4 5 6 7





TELEPHONE: (51 0)622-2648

TELEPHONE: (51 0)622-2625

DATE: 10/24/2005


FACILITY REPRESENTATIVE SIGNATURE: __________ _ DATE: 1 0/24/2005

LIC9099 (FAS) • (06/04) Page: 2 of2

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGEW

/5/5'~ 31-: #0pz_ ~~ C49V~/0

/

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING

COMPLAINT INVESTIGATION REPORT COMPLAINT coNTROL NUMBER f!>Z-cc- 2Pps-/D/91 . &-Z./V>

This is an official report of an unannounced visiVinvestigation of a complaint received in our office on /t:J d?/~ s= and conducted by Evaluator /ikS.Aflb.s.. ~- I

FACILITY NO. FACILITY TYPE FACILITY REPRESENTATIVE

TELEPHONE CAPACITY

~ Cff 9r'7 {'5/D)S'I'9-!<(2z 70 ~ PUBLIC

ALLEGATION(S):

Substantiated 0 Inconclusive

USE LIC 809 FOR ALL CITATIONS LICENSING ANALYST SIGNATURE

>.th-t_ ~£&"lk-NAME OF SUPERVISOR

£~r~ Distribution: Original: Agency LIC 9099 (5100)

Duplicate: Licensee

0 Unfounded 0

TELEPHONE

(5[0) ~Z,z-2~02. TELEPHONE

( ) If

Triplicate: File.

I acknowledge receipt of this form and understand my appeal rights as expla·ned on the back of this form. SIG

Page 1 of __

STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGF

v COMPLAINT INVESTIGATION REPORT

/'S-15" ~ ff/-. • L . ./ ./ ., ' CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

r:F'r ~ , ~ COMMUNITY CARE LICENSING

~~/C4- '7'/~ oz.-cc-z~s-/c/~1 COMPLAINT CONTROL NUMBER tR Z /~$""

This is an official report of an unannounce_d~isiVinvestigation of a complaint received in our office on /tJ// 'f/~s and conducted by Evaluator (!iust9?L-- '1/.oz..f&p-,.._ '

ALLEGATION(S):

~Substantiated D Inconclusive

USE LIC 809 FOR ALL CITATIONS

Distribution: Original: Agency LIC 9099 (5/00)

Duplicate: Licensee

FACILITY TYPE

CG6- fJ/5 FACILITY REPRESENTATIVE

CAPACITY

/0

0 Needs Further Investigation D Unfounded Estimated Days of Completion

TELEPHONE

0 (5£b )62-2-2GO TELEPHONE

( ) (./

Triplicate: File.

I acknowledge receipt of this form and understand my appeal rights as ex lained on the back of this form.

DATE

Page 1 of£__

/5,-/5-~ g1--#=//g Z-STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES Ar CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING

~~~C-4 COMPLAINT INVESTIGATION REPORT t:t</6/z_. COMPLAINT CONTROL NUMBER &z-cc-Z~-5'/6/'fl

0.: A G, Ztc.fr;-" This is an official report of an unannouncedxisMnvestigation of a complaint received in our office on /t1, ~s= and conducted by Evaluator ~Jfi?L.. /l/~ I FACILITY NAME

~/sL FACILITY REPRESENTATIVE

ADDRESS CAPACITY

70

INVESTIGATIONFINDINGS: L_f?/1 ~~ ~

~ Substantiated D Inconclusive

USE LIC 809 FOR ALL CITATIONS LICENSING ANALYST SIG~AT~E- _,.,.

:if/4J:ht ~ NAME OF SUPERVISOR

~ flfth\._ Distribution: Original: Agency LIC 9099 (5100)

Duplicate: Licensee

0 Needs Further Investigation D Unfounded Estimated Days of Completion

TELEPHONE

($"'ft7) ~ZZ-2.t?o TELEPHONE

( ) tl

Triplicate: File.

I acknowledge receipt of this form and understand my appeal rights as explained on the back of this form.

DATE

Page 1 of _I __


FACILITY EVALUATION REPORT BARO-Child Care, 1515 Clay St#1102

FACILITY NAME: DIRECTOR: ADDRESS:

HEARTSLEAPICRIPRESCHOOL

HARDIMAN, JACKIE 2638 COLLEGE AVENUE

Oakland, CA 94612

FACILITY NUMBER:

FACILITY TYPE: TELEPHONE:

CITY: BERKELEY STATE:CA ZIP CODE:

CAPACITY: 70 CENSUS: 60 DATE: TYPE OF VISIT: Case Management UNANNOUNCED TIME BEGAN: MET WITH: Ellie Mashhour TIME COMPLETED:

DEFICIENCY INFORMATION FOR THIS PAGE: CIVIL PENALTY INFORMATION: Type A Penalty Assessed


013416236

850 (510) 549-1422

94704

10/24/2005 11:45 AM 02:30PM

1 In the course of a complaint site visit, a case management visit was also done. Staff files were reviewed. The 2 inside of the facility was toured. Sign-in/out sheets were reviewed. Nap time was observed. 3 4 According to California Code of Regulations, Title XXII, the following deficiencies are observed: 5 6 Citations are on 809 D. 7 8 LIC 311 A was issued and discussed. 9 10 An exit interview was given. Appeal Rights were discussed. 11 12 It is strongly suggested that cubbies for children's belongings be installed such that the clothing and/or 13 bedding of one child do not touch the clothing/bedding of other children. 14 15 16 17 18 19 20 21 22 23





TELEPHONE: (51 0)622-2648

TELEPHONE: (510)622-2625

DATE: 1 0/24/2005



LIC809 (FAS) • (06/04) Page: 1 of 1






Section Cited 3 - -~- ~-

4 101170 Criminal 5 Record Clearance 6

7



101229 4 Responsibility for 5


supervision 7


Section Cited 3 one case "me". Full signature and time is required. 4

101229.1 5 Sign-in/out 6

7

Type A 1 4. Twenty napping children lacked sheet to cover mat. 10/24/2005 2

Section Cited 3 4

101239.1 (c) 5 Napping equipment 6

7





1 Correct by 10/25/05. A Civil Penalty of 2 $800 was assessed. 3 4 5 6 7

1 Correct by 10/25/05. 2 3 4 5 6 7







TELEPHONE: (510)622-2648

TELEPHONE: (510)622-2625

DATE: 11/02/2005



LIC809 (FAS) • (06/04) Page: 2 of 1





Type A 1 5. Ellie Mash hour took over as Director in Sept. 2005. Her 10/24/2005 2 appointment and documents were not submitted in 10 days

Section Cited 3 as required. 4

101212 (b) 5 Reporting 6

Requirements 7

Type A 1 6. LPA reviewed staff records. Six lack Dr. exam. Foru lack 10/24/2005 2 TB test results.

Section Cited 3 4

101217 (a) (12) (13) 5 (b) (10) Personnel 6

Records 7

Type A 1 7. LPA reviewed staff records. Six lacked proof of 10/24/2005 2 educaitonal qualifications.

Section Cited 3 4

101216.1 TEacher 5 Qualifications 6

7

Type A 1 8. Annual License fee has not been paid. 10/24/2005 2

Section Cited 3 4

101187(a) 5 Application/Annual 6

Fee 7


BARO-Child Care,1515 Clay St#1102 Oakland, CA 94612



1 2


3 4 5 6 7

1 2


3 4 5 6 7

1 Correct by 11/25/05. 2 3 4 5 6 7

1 2

Correct by 1 0/31/05.

3 4 5 6 7





TELEPHONE: (510)622-2648

TELEPHONE: (510)622-2625

DATE: 11/02/2005



LIC809 (FAS) • (06/04) Page: 2 of 1


CIVIL PENAL TV ASSESSMENT (Unlicensed and Criminal Background)

BARO·Child Care,1515 Clay St #1102 Oakland, CA 94612

FACILITY NAME DATE

HEARTSLEAPICRIPRESCHOOL 10/24/2005 FACILITY ADDRESS CITY

2638 COLLEGE AVENUE BERKELEY STATE ZIP CODE

CA 94704 LICENSEE(S)/OPERATOR FACILITY NUMBER

INTERNATIONAL CHILD RESOURCE INSTITUTE 013416236

UNLICENSED FACILITY Civil penalties can be assessed against any unlicensed facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1547, 1568.03, 1568.0821, 1569.48, and 1598.891. You are hereby notified that a civil penalty has been assessed. Your facility has been found operating without a license. This is in violation of the California Health and Safety Code Sections 1508, 1568.03, 1569.10, or 1596.80. A Notice of Operation in Violation of Law or Denial of Application was issued on giving notice that failure to submit a completed application or cease operation could result in a civil penalty. O Because you failed to file a completed application or cease operation, a civil penalty of $0.00 is assessed for the period from

through .

0 Residential Care Facility for the Elderly (RCFE): Since a completed application was not submitted by the 15th day, on day 16 from date of notice or letter, $100 per resident per day is being assessed retroactively. From day 16, $200 per resident per day is being assessed until a completed application is submitted or operations cease (if you have not had a previous application denied).

0 Residential Care Facility for the Chronically Ill (RCF-CI): An immediate civil penalty of $100 per resident per day is being assessed. If a completed application is not submitted by the 15th day, on day 16 from date of notice or letter, $200 per resident per day is being assessed until a completed application is submitted or operations cease (if you have not had a previous application denied).

0 Child Care Center, Family Child Care Home, Community Care Facility: since a completed application was not submitted by the 15th day, on day 16 from the date of notice or letter, $200 per day is being assessed until a completed application is submitted or operations cease (if you have not had a previous application denied).

CRIMINAL BACKGROUND CLEARANCE (Immediate) Civil penalties can be assessed for failure to comply with the requirement for fingerprinting and other criminal background requirements, per California Health and Safety Code Sections 1522, 1568.09, 1569.17, 1596.871 and 1596.8712. You are hereby notified that a civil penalty has been assessed. A Facility Evaluation Report (LIC 809) was issued on 10/24/2005 giving notice that your facility has been found in violation of the fingerprinting criminal background clearance requirements.

0

0

0

0

$100 Immediate Civil Penalty per person for failure to obtain a DOJ criminal record clearance or an exemption.

$100 Immediate Civil Penalty per person for failure to request that a previously cleared or exempted person be associated to the facility.

$100 immediate Civil Penalty per parent/authorized representative for failure to provide "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Exclusion)".

$100 immediate Civil Penalty per parent/authorized representative for failure to provide "Family Child Care Home Addendum to Notification of Parents' Rights (Regarding Reinstatement)".

$100 immediate Civil Penalty per parent/authorized representative for failure to obtain signature indicating receipt of Addendum.

$100 immediate Civil Penalty for failure to provide signed addendum to the Department when requested.

§. Number of Persons X $100 = $800.00 Total Penalty YOU WILL RECEIVE A BILL IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL!

NAME OF LICENSING PROGRAM ANALYST NAME OF FACILITY REPRESENTATIVE/TITLE

Susan Neeson Ellie Mashhour SIGNATURE OF LICENSING PROGRAM ANALYST SIGNATURE OF FACILITY REPRESENTATIVE

ITLE

Director 10/24/2005

LIC421A (FAS) • (10/03) Page: 1 of2

UNLICENSED FACILITY

CIVIL PENALTY ASSESSMENT FORM

EXPLANATION TO OPERATOR

A visit was conducted at the facility named on page one of this form by a Licensing Program Analyst. During that visit it was determined that the facility was in operation without having first obtained a license or was continuing in operation after an application for license had been denied.

Since you have failed to cease operation, you must pay the civil penalty until you have confirmed to the satisfaction of the California Department of Social Services that you have ceased operation or have submitted a completed application.

IT IS YOUR RESPONSIBILITY to notify the licensing agency in writing or by the telephone when you have complied.

You will receive a bill in the mail. Payment is due when billed. Payment must be made by a personal, business or cashier's check or money order made payable to the "California Department of Social Services". Please write the invoice number on your check and include a copy of your bill with the payment. You will find the invoice number on your bill.

DO NOT SEND CASH.

CRIMINAL BACKGROUND CLEARANCE (IMMEDIATE)

A visit was conducted at the facility named on page one of this form. During that visit, it was determined that there were persons with client-contact whose fingerprints had not been submitted, or a request for a previously cleared person to be associated to the facility had not been made, as required by law. You must pay the civil penalty until you have confirmed to the satisfaction of the California Department of Social Services that you submitted fingerprints for these persons to the Department of Justice, or requested that a previously cleared person be associated to the facility.

IT IS YOUR RESPONSIBILITY to notify the licensing agency in writing or by the telephone when you have complied.

You will receive a bill in the mail. Payment is due when billed. Payment must be made by a personal, business or cashier's check or money order made payable to the "California Department of Social Services". Please write the invoice number on your check and include a copy of your bill with the payment. You will find the invoice number on your bill.

DO NOT SEND CASH.

APPEAL RIGHTS

The applicant/licensee has a right without prejudice to discuss any disagreement concerning the proper application of licensing laws and regulations, with the licensing agency. When civil penalties are involved, the licensee may request a formal review by the licensing agency to amend, extend the due date, or to dismiss the penalty. Requests for civil penalty appeal must be in writing, must be postmarked within 10 days of receipt of this form, and must be addressed to the District Office of jurisdiction over the facility. The agency has a duty to review the facts presented without prejudice, within a 10-day period. Upon review of the facts upon which the appeal is based, the agency my amend any portion of the action taken, or may dismiss the violation. The licensing agency review of an appeal may be conducted based upon information provided in writing by the licensee. The licensee may request an office interview to provide additional information. The licensee will be notified in writing of the results of the agency review.

LIC421A (FAS) • (10/03) Page: 2 of2

~•~o'"'"~"'-"~~ ~"""~ ''"""''G'""" ' /5/~~ {) f-; FACILITY EVALUATION REPDRT~t~c4- REFERT!>'

See other side for explanation of form. tf tf fd z__

OFFICE 0 ANNOUNCED


FACILITY TYPE

0 PRELICENSING [] ·ANNUAL FOLLOW-UP g'uNANNOUNCED

DEFICIENCY INFORMATION FOR THIS PAGE: ~Type A D No Deficiency Cited

0 T eB

CIVIL PENALTY INFORMATION: ~Penalty Notice Given

D Not A licable POC

DUE DATE

Failure to correct the above cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

TELEPHONE

( 7() ){,2---Z--TELEPHONE

LIC 809 (7/00)

AGENCY COPY Page __J_ of ___;2_ pages


0 FACILITY EVALUATION REPORT See other side for explanation of form.

TYPE OF VISIT: 0 OFFICE 0 PRELICENSING 0 ANNUAL

DEFICIENCY INFORMATION FOR THIS PAGE: ~ Type A D No Deficiency Cited

b T eB


DIRECTOR

FOLLOW-UP

CAliFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING

CIYIL PJ;fi.ALTY INFORMATION: j~ D Penalty Assessed ~Penalty Notice Given

D Penal Cleared 0 Not A licable

PLAN OF CORRECTIONS (POCs)

I

POC DUE DATE


LICENSING EVALUATOR SIGNATURE

8U$JnL /l)?c~ NAM~;t

LIC 809 (7/00)

AGENCY COPY

I understand my licensing appeal rights as ex lained on the back of this form.

Page _k_ of ___2_ pages

ISIS~~ STATE OF CALIFORNIA- HEALTH AND HUMAN SERVICES AGENCY c. #/ ~ tJ i!

-..._/ ~~?O-f- REFER rb--"' FACILITY EVALUATION REPORT· 'fLCt,/2-see other side for explanation of form.

DIRECTOR

~ MANAGEMENT 0 MET WITH


0 FOLLOW-UP ~UNANNOUNCED

CIVIL PENALTY INFORMATION: D No Deficiency Cited·

COMMENTS/DERCIENCIES

Ltc '7/!JJ ~ ~ e, ~.

~Penalty Notice Given

0 Not A licable

PLAN OF CORRECTIONS (POCs) POC DUE DATE


LIC NSING EVALUATOR SIGNATURE TELEPHONE

~ ( 10> ~zz-TELEPHONE /'"7 /_

( )~02 LIC 809 (7/00)

AGENCY COPY Page~ of 3_ pages

STATE OF CALIFORNIA· HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CIVIL PENALTY ASSESSMl:1<JT

LICENSEE(S)/OPERATOR

4-Pvov~ FACILITY#:

LICENSED FACILITY

Civil penalties can be assessed against any facility which fails to take corrective action within prescribed time periods, per California Health and Safety Code Sections 1548, 1568.0822, 1569.49, 1596.99. You are hereby notified that a civil penalty has been assessed.

The above facility has been found in violation qf t!l~ Californi<!,C~qe of Regula!,l9)1S, Title 22, Divisions 6, and/or 12, Section(s) /t?l/11? ~'<u-P-rd ~~

and/or California Health and Safety Code, Chapters 3, 3.01, 3.2, 3.4, and 3.5

Section(s) ---------------------------------------

A Facility Evaluation Report {LIC 809} was issued on / t? /-@e;:' 5> giving notice that failure to correct the above violation(s) would result in a civil penalty.

t9t? ~ Because you failec}to~ke the corrections spe;: .. ifie9 9n the LIC 809, a civil penalty of $ %Po ~ is assessed for the

period from I &I Z _ ~ through /t2(J-- ~'UP'p S': ~ E A E

0 A civil penalty of $50 per violation per day, up to a maximum of $150 per day will be assessed. This will continue until correction(s) are made to comply with the licensing laws, regulations, and approval of the California Department of Social Services or authorized licensing agency.

0 Because you repeated a violation of the same subsection within a 12 month period, an immediate civil penalty of $ is assessed for , the day the deficiency was cited.

DATE

0 All Facility Types: Second citation within a 12 month period; an immediate civil penalty of $150 per violation then $50 per day per violation until corrections are made.

0 Residential Care Facility for the Elderly (RCFE), Residential Care Facility for the Chronically Ill (RCF-CI): Third citation within a 12 month period; an immediate civil penalty of $1,000 per violation then $100 per day per violation until corrections are made.

0 Child Care Centers, Community Care Facility (CCF): Third citation within 12 month period; an immediate civil penalty of $150 per violation then $150 per day per violation until corrections are made.

0 Violations which result in injury, sickness, or death: An immediate civil penalty of $150 per violation then $150 per day per violation until corrections are made.

YOU WILL RECEIVE A BILL IN THE MAIL.

DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR BILL

NAME OF LICENSING PROGRAM ANALYST NAME OF FACILITY REPRESENTATIVE/TITLE

E/1/-e ;Jta5Ahou1/ SIGNATURE OF LICENSING PROGRAM ANALYST

NAME OF DEPARTMENTAL REVIEWER AND TITLE

LIC 421 (4/00)