STATE OF CALIFOEATH AND HUMAN SERVICES AGENCY . COMPLAINT INVESTIGATION REPORT This is an official report of an unannounced visitlinvestigation of a complaint received in our oflice on 03I15l2012 and conducted by Evaluator Mayla Mendoza CONFIDENTIAL COMPLAINT CONTROL NUMBER: 02-CC-20120315151057 FACILITY NAME: St. Andrews Church FACILITY NUMBER: Unlicensed ADMINISTRATOR: FACIUTY TYPE: UN LIC ADDRESS: 2624 West Street . TELEPHONE: CITY: Oakland STATE: ZIP CODE: 94612 - CAPACITY: CENSUS: 14 DATE: 03I20I2012 T1ME VISIT BEGAN: 01:20 PM MET WITH: Robert Lacy. JR. TIME COMPLETED: 02:15 PM ALLEGATIONISI: 1 UNLICENSED DAY CARE . INVESTIGATION FINDINGS: 1 LPA MAYLA MENDOZA VISITED THE CENTER BASED ON THE ALLEGATION ABOVE. A CENSUS WAS 2 TAKEN AND INTERVIEWS WERE CONDUCTED. CENTER SAYS THEY ARE A PRIVATE SCHOOL AND 3 SERVE CHILDREN K-12. ST. ANDREWS HAS AN AFFIDAVIT BUT WAS NOT AVAILABLE. . 4 I 5 LPA WILL NEED FURTHER TIME TO INVESTIGATE THIS 6 7 EXIT INTERVIEW WAS CONDUCTEDNeeds Further Investigation Estimated Days of Completion: NAME: Ann Robinson TELEPHONE: (510) 622-2591 LICENSING EVALUATOR NAME: Mayla Mendoza TELEPHONE: (510) 622-2602 LICENSING EVALUATOR SIGNATURE: I acknowledge receipt of this fonn and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: mr DATE A- This report must be available at Child Care and Group Home facilities for public review for 3 years. ucam (ns} Pam: 1 ol'2 sure OF cAu=onHIA - HEALTH me HUIIAN ssnvicas Aomcv CAIJFORMA or SOCIAL SERVICES coumunm CARE ucansna uvlston COMPLAINT INVESTIGATION REPORT 11 This is an official report of an unannounced visithnvestigation of a mmplaint received in our office on 03/15/2012 and conducted by Evaluator Mayla Mendoza CONFIDENTIAL COMPLAINT CONTROL NUMBER: 02-CC-20120315151057 FACILITY NAME: St. Andrews Church FACILITY NUMBER: Unlicensed ADMINISTRATOR: FACILITY TYPE: UNLIC ADDRESS: 2624 West Street TELEPHONE: CITY: Oakland STATE: ZIP CODE: 94612 CAPACITY: CENSUS: 0 DATE: 03/21/2012 TIME VISIT BEGAN: 01:39 PM MET WITH: TIME COMPLETED: 01:45 PM 1 UNLICENSED CARE INVESTIGATION FINDINGS: 1 LPA MAYLA MENDOZA MET WITH ROBERT LACY, JR ON 3/20/12 REGARDING THE ABOVE 2 ALLEGATION. - 3 THROUGH INTERVIEWS AND INVESTIGATION THE ALLEGATION AGAINST OPERATING A CHILD CARE 4 CENTER WITHOUTA LICENSE HAS BEEN DETERMINED AS UNFOUNDED. LPA DID NOT OBSERVE PRE 5 SCHOOL CHILDREN AT THE FACILITY. THERE WERE 12 SCHOOL AGE CHILDREN AT THE FACILITY. ST. 6 ANDREW CHURCH HAS AN AFFIDAVIT LISTED ON THECALIFORNIA DEPT. OF EDUCATION WEBSITE 7 FOR THE 2011-2012 PRIVATE SCHOOL YEAR. AFFIDAVIT ID NUMBER IS 113257. 8 2608 IS CURRENTLY ST. ANDREWS ADDRESS. 2624 IS THE OLD ADDRESS BEFORE THE MERGE OF 9 THE BUILDINGS. 2618 IS AN ABANDONED HOUSE NEXT TO THE CHURCH. 10 11 12 THIS COMPLAINT IS WITHOUT A REASONABLE BASIS AND IS THEREFORE DISMISSED. 13 REPORT IS BEING MAILED TO THE FACILITY, THEREFORE A SIGNATURE WAS NOT ACOUIRED, AND BASED ON THE FINDINGS, A SIGNATURE WAS NOT Unfounded Estimated Days of Completion: NAME: Ann Robinson TELEPHONE: (510) 622-2591 LICENSING EVALUATOR NAME: Mayla Mendoza TELEPHONE: (510) 622-2602 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2012 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: I DATE: 03/21/2012 Control Number 02-CC-20120315151057 STATE or CALIFORMA - ashun mo rrunmr SERVDES AGENCY cnuronnu DEPARTMENT or IOCIAL I 1515 STREET SUITE DETAIL SUPPORTIVE INFORMATION D. mum lntenrrew--Sta1T This fom1 is intended to document infom1ation that is relevant to the licensing tile but generally not public infomation, such as collateral visits. This would include back-up information on deficiencies such as conditions contributing to the severity of violations, witnesses to the violations, or other observation from tield notes. When used to support the Licensing Report the form should be completed, signed and dated shortly after the visit. This assures accurag and completeness of the detail of the public regrt. CONFIDENTIAL FACILITY NAME: FACILITY NUMBER: DATEISI OF CONTACT: COLLATERAL St. Andrews Church Unlicensed 03/20/2012 No 1 LPA Mayla Mendoza made a visrt to St. AnH@s Church on a compIaInt investigation. Upon arrival, LPA was 2 greeted by Carrie Banks, Teacher/Admin. stall'. 3 4 CARRIE BANKS, STAFF: 5 Carrie informed LPA that the school is a private school and that no pre--schooIers were being red for. LPA 6 asked for their aflidavit but was not available. Ms. Banks contacted Dr. Robert Lacy, Principal and Founder of St. 7 Andrew Church. LPA spoke to Dr. Lacy on the phone and infonned LPA to look up the affidavit on-line because 8 he would not give LPA a copy. LPA toured the facility and obsenred 14 school-a children. 9 10 ROBERT LACY, JR, TEACHER, SON OF DR. ROBERT LACY: 11 Robert Lacy JR also infom1ed LPA that the school does have an affidavit but tl1at it was locked up in his fathers 12 office upstairs. Robert also stated that there are no preschool children in care. Robert also stated that someone 13 may have been misinformed about them having a day care at the moment because Robert said that they are 14 planning to build a child care facility. On the school's tlyer, 2 additional buildings were drawn out because of the 15 school's plan on building an infant/toddler pro ram in the future. LPA asked about addresses 2608 and 2618. 16 Robert mentioned that St. Andrevfs address is 2608. 2624 is there old address before the city merged the 17 buildings. 2618 is the abandoned house next doorLICENSING EVALUATOR NAME: Mayla Mendoza TELEPHONE: (510) 622-2602 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2012 ucm rms; rr?En.souAucoun?EumL oeraroruo on TYPE or wronnmou; I