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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422739
Report Date: 04/28/2022
Date Signed: 04/28/2022 03:44:21 PM

Document Has Been Signed on 04/28/2022 03:44 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:MIROV, CHRISTINEFACILITY NUMBER:
013422739
ADMINISTRATOR:MIROV, CHRISTINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 910-4694
CITY:OAKLANDSTATE: CAZIP CODE:
94618
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
04/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Christine Mirov TIME COMPLETED:
04:00 PM
NARRATIVE
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On 4/28/22 at 2:50PM, Licensing Program Analyst (LPAs) Catherine Fernandes and Indira Loza arrived unannounced for a case management visit regarding an incident that happened on 4/20/22. LPAs met with Licensee Christine Mirov. There were no children in care during the visit.

There was an incident that was reported by the licensee regarding a child that walked out of the day care unsupervised on 4/20/22. Within in minutes the child was brought back inside the day care unharmed, by a staff member. Parents and Licensing were informed of the incident.

Due to the incident a citation is being issued.

There is an immediate civil penalty of five hundred dollars ($500) being assessed today for violating a zero tolerance deficiency.

The attached type A violations is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgment form of proof of receiving this report (LIC9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing.


Exit interview conducted
Report and Appeal Rights provided
Notice of site visit must be posted.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Catherine Fernandes
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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 04/28/2022 03:44 PM - It Cannot Be Edited


Created By: Catherine Fernandes On 04/28/2022 at 02:57 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: MIROV, CHRISTINE
FACILITY NUMBER: 013422739

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited
HSC
1597.58(c)2

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HEALTH AND SAFETY CODE: ZERO TOLERANCE ABSENCE OF SUPERVISION.
Includes but is not limited to a child(ren) left unattended, a child left alone with a person under 18 years of age and a lack of supervision resulting in a child(ren) wandering way. The following requirement is not being met as evidenced by:
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Licenseee is to come witha plan to ensure children do not leave the home unattended and submit the proof of corrections by proof of correction date.

The following is a zero tolerance deficienciy and the home is being assessed a $500 civil penalty.
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Based on a report made by the licensee a child left the day care unsupervised, which is an immediate danger to 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:Catherine Fernandes
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
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