070206625-3-16-2022-02-CC-MSUN-CCKRMT-20220316130917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 070206625
Report Date: 03/16/2022
Date Signed: 03/16/2022 01:09:33 PM

Document Has Been Signed on 03/16/2022 01:09 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:	CLAYTON VALLEY PRESBYTERIAN CHILDREN'S CENTER		FACILITY NUMBER:	070206625
ADMINISTRATOR:	MILLER, MICHELLE		FACILITY TYPE:	850
ADDRESS:	1578 KIRKER PASS ROAD		TELEPHONE:	(925) 672-0882
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY:	63	CENSUS: 28	DATE:	03/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Kristi Buchholz		TIME COMPLETED:	01:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/16/22 Licensing Program Analyst (LPA) Michelle Sutton conducted an unannounced Annual Inspection at Clayton Valley Presbyterian Children's Center. LPA met with Director, Krisiti Buchholz and explained the purpose of today's inspection. LPA was granted inspection authority to enter the facility. The facility was toured to conduct a Health and Safety Inspection. Facility's operating days and hours are Monday to Friday 7:00 AM to 5:00 PM. Director Kristi Buchholz was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. The physical plant was inspected. LPA toured the premise with the Director. Indoor space: Facility operates in 2 Rooms - Butterfly room(2-3 year olds) and Beavers Room (4 year olds). LPA observed Teddy Bear room but is not being used at this time. Facility was observed to be in compliance with teacher to children ratio requirement during LPA's inspection. The classrooms, restrooms, food storage areas and spaces accessible to children were inspected. Disinfectants, cleaning solutions, poisons and other items that are dangerous to the health and safety of children were stored in places inaccessible to them. Storage areas for poisons were locked and medications were kept in a safe place inaccessible to children. Cabinets, drawers, and rooms used for storage were locked. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. Continue 809-C page

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle Sutton	TELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CLAYTON VALLEY PRESBYTERIAN CHILDREN'S CENTER	FACILITY NUMBER: 070206625
	VISIT DATE: 03/16/2022

NARRATIVE

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Restrooms for children were observed in each classroom, all toilets, hand washing are safe and sanitary operating condition. All floors were clean and safe. Foods and beverages were stored safely. Food storage area were clean, free of litter, rubbish, and free of rodents and other vermin. Trash cans for solid waste had tight-fitting covers on and were in good repair. Director stated that facility does not possess nor store any weapons on the premises. LPA observed Fire extinguishers, Smoke Detectors and Carbon Monoxides Detectors in each classroom. All materials and surfaces accessible to children appeared to be toxic free. Menus were observed to be posted at least 1 week in advance in a place visible by the child’s authorized representative, dated and kept on file for 30 days and made available upon request.

Outdoor Space: Outdoor playground was inspected and observed to be fenced and safe. The play equipment was maintained in good condition and free of hazards. Surface of the outdoor activity space was in safe condition and free of hazards. Areas around and under high climbing equipment and slides were cushioned with material that absorbs falls. There were no bodies of water observed. Drinking water is readily available to children during indoor and outdoor activities.

File Review: Children sign in and out procedures and logs were reviewed. All children were signed in by their authorized representative with full legal signatures. A sample of10 (10) Children's files and five (6) Staff files was taken for review.
Child files contained LIC700 Information and Emergency Forms and Medical Assessments – Physician’s Report LIC701, Child’s Preadmission Health History - Parent Report LIC702 and immunization record.
Staff files contained their Personnel Record LIC501 with Health Screening, immunization. There was at least one staff present with current certification in Pediatric CPR and First Aid at the facility during inspection. There was 1 staff not up to date with Mandated Reporter Training. Children's Roster and Personnel Report was reviewed, and a copy obtained.

Continue 809-C Page

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle Sutton	TELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: CLAYTON VALLEY PRESBYTERIAN CHILDREN'S CENTER	FACILITY NUMBER: 070206625
	VISIT DATE: 03/16/2022

NARRATIVE

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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPA discussed the safe sleep regulations with licensee Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

The following Technical Violation was discussed. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director Kristi Buchholz.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle Sutton	TELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC809 (FAS) - (06/04)

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