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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070206625
Report Date: 02/24/2023
Date Signed: 02/24/2023 03:23:34 PM


Document Has Been Signed on 02/24/2023 03:23 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 CENTERFACILITY NUMBER:
070206625
ADMINISTRATOR:KRISTINE BUCHHOLZFACILITY TYPE:
850
ADDRESS:1578 KIRKER PASS ROADTELEPHONE:
(925) 672-0882
CITY:CLAYTONSTATE: CAZIP CODE:
94517
CAPACITY:63CENSUS: 24DATE:
02/24/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kristine BuchholzTIME COMPLETED:
02:30 PM
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On 2/24/23, Licensing Program Analysts (LPAs) Melissa Guirit and Melissa Domantay arrived on a case management inspection and met with Director Kristine Buchholz. There were 24 children present in care and six staff members.

The purpose of the visit was due to a self reported incident that was sent to the Oakland Regional office regarding two children on the playground. Staff interviews were conducted.

No deficiencies cited during today's visit.

Notice of site visit and copy of reports provided.

Exit interview conducted with Director, Kristine Buchholz.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Melissa GuiritTELEPHONE: (510) 566-8898
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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