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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070208893
Report Date: 11/16/2022
Date Signed: 11/16/2022 03:59:02 PM


Document Has Been Signed on 11/16/2022 03:59 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:SRVSACCA - KIDS COUNTRY-VISTA GRANDEFACILITY NUMBER:
070208893
ADMINISTRATOR:GRAVELYN, JEANETTEFACILITY TYPE:
840
ADDRESS:667 DIABLO ROADTELEPHONE:
(925) 837-0330
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:120CENSUS: 76DATE:
11/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jeannette GravelynTIME COMPLETED:
04:20 PM
NARRATIVE
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On 11/16/22 at 1:30 pm Licensing program Analyst (LPA) Monica Mathur conducted an unannounced inspection at SRVSACCA - Kids Country - Vista Grande school-age program which is located in the premises of Vista Grande Elementary School. LPA met with Director, Jeannette Gravelyn and explained the purpose of the visit.

Facility self reported an unusual incident which occurred on 11/11/22 when a child (C1) left the premises from the playground, unattended. Investigation determined child was missing for approximately 20 minutes.

LPA interviewed Director and a staff (S1) who was present at the time of incident and reviewed surveillance footage. Other 2 staff present during incident were not present today and could not be interviewed. It was determined on 11/11/22 there were 3 staff and 33 children in the playground. Some utility workers who were working at the far end of the play ground, opened a gate and drove their trucks into the playground. The gate was supposed to always remain locked and staff was unaware gate had been unlocked. At about 10:45 am a co-worker visiting from another sister facility went to the playground to meet the staff outside. All staff congregated for a few minutes and at about 10:50 am it is believed C1 left through the unlocked/unsupervised gate. At around 11 am staff noticed C1 missing during a head count C1 had tried to walk back home, but was retrieved by a good samaritan neighbor. At about 11:12 am C1's parent brought C1 back to the facility and reported the incident to Director. Meantime staff were still trying to locate child. Elementary school was closed but school age program was operating that day.
This is an absence of supervision, and posed an immediate risk to the health and safety of a child. Type A deficiency is cited on page 809D and civil penalty of $500 assessed.
continued next page.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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: SRVSACCA - KIDS COUNTRY-VISTA GRANDE
FACILITY NUMBER: 070208893
VISIT DATE: 11/16/2022
NARRATIVE
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LPA Monica Mathur informed Director that this report dated 11/16/22 with 1 Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Mathur informed Director to provide a copy of this licensing report dated 11/16/22 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

This report was reviewed with Director, Jeannette Gravelyn and Notice of Site Visit was given which must be posted for 30 days.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/16/2022 03:59 PM - It Cannot Be Edited

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: SRVSACCA - KIDS COUNTRY-VISTA GRANDE
FACILITY NUMBER: 070208893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited

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101229 Responsibility for Providing Care & Supervision (a) (a) The licensee shall provide care and supervision as necessary to meet the children's needs (1) No child(ren) shall be left without the supervision of a teacher at any time [...] Supervision shall include visual observation. This requirement is not met as evidenced by:
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By investigation it was determined C1 left the premises unsupervised and unattended, was missing for approx. 20 minutes. This posed an immediate risk to safety of child.
Civil penalty of $500 assessed.
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BY POC DUE DATE 11/17/22 hold all staff training on Supervision, watch video on CCLD website and submit agenda and signed attendance of participation.
www.ccld.ca.gov

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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: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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