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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421292
Report Date: 06/07/2023
Date Signed: 06/07/2023 03:31:25 PM

Document Has Been Signed on 06/07/2023 03:31 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: 0CENSUS: 8DATE:
06/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Dorothea RaymondTIME COMPLETED:
03:40 PM
NARRATIVE
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On June 7, 2023 at 9:02am Licensing Program Analyst (LPA) Indira Loza arrived at the facility to conduct a required case management. Present for the inspection were Assistant Kristen Garcia, an additional assistant, and 7 preschool age children and one infant. The Licensee came down about 20 minutes into the inspection.
At approximately 9:15am, the LPA found that the 2nd assistant did not have a cleared background. A Type A citation with a Civil Penalty is being issued for this deficiency.

The LPA reviewed staff files, and found three of five were missing a Mandated Reporter certificate. LPA also reviewed the children files and found none to have the LIC9224 for the Non-Compliance conference held on May 11, 2023. Two Type B citations were issued for the deficiencies.

The following deficiencies were cited during today's visit:
1) Type A - Criminal Record Clearance
2) Type B - Mandated Reporter Certificate
3) Type B - Failure to maintain signed LIC9224s in the children files.

As a courtesy the LPA printed an LIC126 (Entrance Checklist for Family Child Care Homes, and two LIC9224s (Acknowledgment of Receipt of Licensing Reports). One LIC9224 is for the Non-Compliance Conference held on May 11, 2023, and the second LIC9224 is for the Type A deficiency issued on June 7, 2023.

The LIC9224s must be signed by currently enrolled children, and for newly enrolled children for the next 12 months. The LIC9224s must be kept in the children's files.

The LIC9224s, the LIC126, and the report was reviewed with Licensee Dorothea Raymond.
Appeal Rights and a Notice of Site Visit were given to the Licensee.
The Notice of Site Visit and reports must remain posted for 30 days.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2023
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 3
Document Has Been Signed on 06/07/2023 03:31 PM - It Cannot Be Edited


Created By: Indira Loza On 06/07/2023 at 02:48 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: 06/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/08/2023
Section Cited
CCR
102370(d)(1)

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(d) 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:(1) Obtain a California clearance or a criminal record exemption as required by the Department
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The Licensee shall have the adult leave the premises, no later than June 7, 2023, and not return until they have a cleared background check. LPA will be returning in 10 days to verify the uncleared adult is not present at the facility.
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This requirement was not met as evidenced by: Based on record review and interview it was determined an adult at the facility did not have cleared fingersprints which poses an immeditae Health and Safety risk to the children in care.
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Type B
07/07/2023
Section Cited
HSC1596.8662(b)(1)

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On or before March 30, 2018, a person who...is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training...and shall complete renewal mandated reporter training every two years following the date on which
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The Licensee shall submit a Mandated Reporter certificate to the LPA no later than July 7, 2023.
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he or she completed the initial mandated reporter training.This requirement is not met as evidenced by: Based on interview and record review 3 of 5 staff did not have a Mandated Reporter certificate, which poses a potential risk to tthe 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:Mayla Mendoza
LICENSING EVALUATOR NAME:Indira Loza
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/07/2023 03:31 PM - It Cannot Be Edited


Created By: Indira Loza On 06/07/2023 at 03:01 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: 06/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/07/2023
Section Cited
HSC
1696.8595(c)(1)

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Health and Safety Code Section 1596.8595 (c) A licensed child care facility or home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the
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The Licensee shall send the LPA a copy of all signed LIC9224s (one for the Non-Compliance ceonference held on May 11, 2023 and another for the Type A deficiency issued on June 7, 2023) no later than July 7, 2023.
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health, safety, or personal rights of children in care...This requirement was not met as evidenced by: Based on record review it was determined that none of the children had the LIC9224 in their file, which 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: 06/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023


LIC809 (FAS) - (06/04)
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