070208034-9-1-2022-52-CC-MOTI-CHUS5Y-20220901133506

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 070208034
Report Date: 09/01/2022
Date Signed: 09/01/2022 01:35:12 PM

Document Has Been Signed on 09/01/2022 01:35 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME:	SRVSACCA - KIDS COUNTRY-WALT DISNEY		FACILITY NUMBER:	070208034
ADMINISTRATOR:	HIATT, MOLLY		FACILITY TYPE:	840
ADDRESS:	3250 PINE VALLEY ROAD		TELEPHONE:	(925) 552-4489
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	120	CENSUS: 26	DATE:	09/01/2022
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Rowena Alegre		TIME COMPLETED:	01:40 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	A Case Management Inspection was conducted on this date 09/01/2022 by Licensing Program Analyst (LPA) Melanie Otsuji. LPA met with Director, Rowena Alegre. An application was submitted for an Addition of a Room. The center has requested to add a room AC17 as licensed space. The school age program is located on Walt Disney Elementary School campus. The program is currently utilizing the Kids Country Modular and T3 on school grounds. Hours of operation are from 7:00AM to 6:30PM, Monday through Friday. Present today were 7 additional staff members and 26 school aged children. A health and safety inspection was conducted inside and outside. INDOORS: EXEMPT OUTDOORS: EXEMPT This facility is exempt from square footage and bathroom requirements. Facility utilizes the playground and blacktop on school grounds as well as facility's own courtyard. Drinking water is available inside and outside by way of water fountains and bottles brought from home. Facility provides AM/PM snacks. Menus are posted. Facility has a functioning carbon monoxide detector, smoke detector and fire extinguisher. Facility has a sign in/out sheet that allows ample space for full legal signature and records time and date. An approved Fire Clearance was received on 08/18/2022 from San Ramon Valley Fire for 120 school aged children.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Melanie Otsuji	TELEPHONE: (510) 622-2613
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRVSACCA - KIDS COUNTRY-WALT DISNEY	FACILITY NUMBER: 070208034
	VISIT DATE: 09/01/2022

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
26
27
28
29
30
31
32

All licensing required documents are posted. Per Director, all Opening and Closing staff have current Pediatric CPR/First Aid. This facility plans to provide Incidental Medical Services – IMS. An updated Plan of Operation that includes IMS must be submitted to the Department when any changes are made. 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.

Mandated reporter and appeal rights, civil penalties, unusual incident reporting and fingerprint requirements were discussed today. Director is also being informed of the web address (www.ccld.ca.gov) for downloading child care forms, and the director is encouraged to email ChildCareAdvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The director is also reminded that mandated reporter training is required for all staff and is to be renewed every 2 years at www.mandatedreporterca.com.

Zero Tolerance policies were explained.
The center was found to be clean, safe, sanitary and in good repair.

There are no deficiencies cited during today's visit. A license with approval for 120 school aged children operating out of Kids Country Modular, T3, and AC17 will be issued effective, 9/1/2022.

An exit interview was conducted.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Melanie Otsuji	TELEPHONE: (510) 622-2613
LICENSING EVALUATOR SIGNATURE:	DATE: 09/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2