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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421292
Report Date: 07/12/2023
Date Signed: 07/12/2023 12:40:49 PM

Document Has Been Signed on 07/12/2023 12:40 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:
07/12/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Kristen Garcia and Rashno RazmkhahTIME COMPLETED:
12:50 PM
NARRATIVE
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On July 12, 2023 at 10:15am Licensing Program Analyst (LPA) Indira Loza met with Assistants Kristen Garcia and Rashno Razmkhah, the Licensee was not during today's visit. LPA arrived to the facility for the purpose of conducting a POC visit for two deficiencies cited on June 7, 2023.

One citation was for Mandated Reporter Certificates where three of five staff did not have a certificate. LPA was presented with a Mandated Reporter Certificate for one staff, but two staff persons do not have a certificate.

Another citation was for the failure to have the Acknowledgment of Receipt of Licensing Reports (LIC9224) for a Non-Compliance conference held on May 11, 2023. LPA reviewed the children's files and there was no LIC9224 for either the Non-Compliance conference held on May 11, 2023 and the Type A citation issued on June 7, 2023.

Due to The Mandated Reporter Certificates not being available upon review during today's visit and the Acknowledgment of Receipt of Licensing Reports (LIC9224) not in the children's files the facility will be re-cited with a Civil Penalty Assessment.

See LIC809-D for the citations.

Report and Appeal Rights provided to Assistant Kristen Garcia.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Indira Loza
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2023
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 07/12/2023 12:40 PM - It Cannot Be Edited


Created By: Indira Loza On 07/12/2023 at 10:38 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: RAYMOND, DOROTHEA
FACILITY NUMBER: 013421292

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2023
Section Cited
HSC
1596.8662(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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Licensee shall submit two certificates for the staff (Licensee and asst. R. GravesSmith). The Licensee shall submit the certificates no later than July 31, 2023.
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he or she completed the initial mandated reporter training.This requirement is not met as evidenced by: The Mandated Reporter certificates were not sent to LPA and were not available for review during today's visit, which poses a potential risk to tthe health and safety of children in care.
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Type B
07/31/2023
Section Cited
HSC1696.8595(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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Licensee shall submit the LIC9224s for the Non-Compliance Conference, no later than July 31, 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: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023


LIC809 (FAS) - (06/04)
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