070210967-5-16-2022-52-CC-JPLA-CEGS3Y-20220516133156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 070210967
Report Date: 05/16/2022
Date Signed: 05/16/2022 01:32:06 PM

Document Has Been Signed on 05/16/2022 01:32 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 AT COUNTRY CLUB SCHOOL		FACILITY NUMBER:	070210967
ADMINISTRATOR:	SANTOS, YVETTE		FACILITY TYPE:	840
ADDRESS:	7534 BLUE FOX WAY		TELEPHONE:	(925) 552-4483
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	120	CENSUS: 13	DATE:	05/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Pia Mancini		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	On May 16, 2022 at 9:00am, Licensing Program Analyst (LPA) Julia Placencia arrived unannounced for a Required-1 Year inspection. LPA met with assistant director Pia Mancini. There were 13 children and an additional 6 staff members present during the inspection. The facility was toured for a health and safety inspection. Hours of operation are Monday through Friday, 7:00am to 6:30pm. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children were inaccessible during the visit. The toilets and sinks were in operable condition. The floors are free of tripping hazards. The kitchen/food preparation and storage areas appear to be clean and free of evidence of rodents and food is protected against contamination. All storage containers for solid waste have tight-fitting covers that are in good repair. Drinking water is available both indoors and outdoors. Menus are posted near front entrances. There are no pools or similar bodies of water at this facility. Outdoor activity space and playground equipment observed to be safe and free of hazards. Climbing equipment is properly anchored to the ground with adequate and appropriate cushioning material to absorb falls. There is a shaded area provided for the children. Required licensing documents were posted. Fire extinguishers, carbon monoxide and smoke detectors meet State Fire Marshall standards. The facility is operating within its licensed capacity. The facility is within ratio today with 1 teacher supervising no more than 14 children. LPA did not observe any child left without visual supervision or unattended during the inspection. LPA verified both opening and closing staff have current CPR/First aid training. Children's records reviewed contain required licensing documents. Staff have required immunizations and mandated reporter training. Teachers meet qualification requirements. A physical census was taken of all children present and crossed referenced with the sign in/out sheets. Fire/Disaster drills are conducted monthly and the last drill was conducted on 4/5/22. ***Continued on LIC 809C...

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRVSACCA - KIDS COUNTRY AT COUNTRY CLUB SCHOOL	FACILITY NUMBER: 070210967
	VISIT DATE: 05/16/2022

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 Center 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.

Facility representative 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.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to also email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list.

There were no deficiencies cited during today’s inspection.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the assistant director Pia Mancini.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Julia Placencia	TELEPHONE: (510) 725-5998
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

LIC809 (FAS) - (06/04)

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