<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070208893
Report Date: 12/21/2022
Date Signed: 12/21/2022 04:52:10 PM


Document Has Been Signed on 12/21/2022 04:52 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: 54DATE:
12/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jeannette GravelynTIME COMPLETED:
05:15 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 12/21/22 at 3:00 pm Licensing Program Analysts (LPAs) Monica Mathur and Christina Watts conducted an unannounced inspection at SRVSACCA - Kids Country - Vista Grande school-age program located in the premises of Vista Grande Elementary School. LPAs met with Director, Jeannette Gravelyn and explained the purpose of the inspection. Facility self reported an unusual incident which occurred on 12/16/22 when a child (C1) left the premises unattended. LPAs conducted staff interviews, facility inspection and obtained documents.

Investigation determined on 12/16/22 child C1 asked staff S1 to use the restroom located in the hallway that connects two rooms on either side. When S1 gave permission, C1 ran to the hallway. S1 followed C1 and assumed child went into the restroom. When C1 did not come out for couple of minutes, S1 checked the restroom and did not find C1 inside. S1 alerted the Director who was in the kitchen. It is assumed when C1 ran to the hallway, child did not go into the restroom, instead ran through the hallway into the empty room on the other side, pushed the front door open and ran out of the premises. This incident happened at 12:30 pm during lunch time and facility has CCTV footage. Director called C1's parent immediately, alerted elementary school and staff searched for C1. Director got into her car and drove around the neighborhood and found C1 couple of stop lights away, with a neighbor. Director returned with C1 at around 12:47 pm. C1 was missing for approximately 15 minutes.

It is noted that in an incident that occurred a month ago, the same child C1 had left the facility premises unnoticed and was found by the same neighbor. Facility was cited Type A on 11/16/22 with $500 civil penalty.

During today's inspection, it was determined absence of supervision resulted in C1 leaving facility unattended. Type A deficiency is cited today. This is a second repeat violation within 12 months and civil penalties of $250 assessed today.
continued on 809-C
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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 3


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: 12/21/2022
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
LPA Monica Mathur informed Director that this report dated 12/21/22 with 1 Type A citation 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 12/21/22 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.

Director was informed a Non-Compliance Conference will be scheduled to discuss recent deficiencies.

Exit interview conducted and report was reviewed with Director, Jeannette Gravelyn. A Notice of Site Visit was given and must remain posted for 30 days

Failure to correct deficiency will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/21/2022 04:52 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: 12/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2022
Section Cited

1
2
3
4
5
6
7
101229 Responsibility for Providing Care & Supervision (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:

1
2
3
4
5
6
7
By end of 12/22/22 Director agreed to submit a written plan on what steps have been implemented and further steps on how they will comply with this regulation.
8
9
10
11
12
13
14
Investigation determined C1 left the premises unsupervised and unattended, was missing for approx.15 minutes. This posed an immediate risk to safety of child.
Civil penalty of $500 assessed.
8
9
10
11
12
13
14
Failure to correct deficiency will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 12/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3