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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421292
Report Date: 04/13/2023
Date Signed: 04/13/2023 05:32:00 PM

Document Has Been Signed on 04/13/2023 05:32 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:RAYMOND, DOROTHEAFACILITY NUMBER:
013421292
ADMINISTRATOR:RAYMOND, DOROTHEAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 938-6666
CITY:BERKELEYSTATE: CAZIP CODE:
94706
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
04/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Sebastian Szekalski TIME COMPLETED:
05:32 PM
NARRATIVE
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On April 13, 2023 at 9:01am Licensing Program Analyst (LPA) Indira Loza met with Assistants Sebastian Szekalski and Kristen Garcia to continue the investigation for the above allegation. Present during the inspection were the Licensee's two assistants and six preschool age children and one infant. A third assistant, Rajanique Graves-Smith, arrived at around 12:30pm. LPA conducted a tour of the home for a Health and Safety check.

While at the home LPA conducted staff and children interviews which revealed that the toilet designated as "on limits" for the children to use was out of order. The staff were unable to get a hold of the licensee and had to take the children to the upstairs bathroom which is in an "off limits" area.

This poses an immediate risk to the health and safety of the children in care.
Title 22 is being cited on the attached LIC 809D.

Exit interview conducted with assistant Sebastian Szekalski.
Appeal Rights, Report, and Notice of site visit provided.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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 04/13/2023 05:32 PM - It Cannot Be Edited


Created By: Indira Loza On 04/13/2023 at 04:19 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: RAYMOND, DOROTHEA
FACILITY NUMBER: 013421292

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
102416.3(a)(6)

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Alterations to Existing Buildings or Grounds - (a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of ...(6)Any change from an area of the family child care home previously identified as "off limits" to an area where care and
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Licensee shall fix the "on limits" toilet so children can use the bathroom in the designated "on limit" areas.
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supervision will be provided ... This requirement was not met as evidenced by: Based on children and staff interviews it was determined tha tthe children were take to use a bathroom designated as "off limits". This poses a potential health and safety risk to the 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:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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