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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070210990
Report Date: 01/21/2020
Date Signed: 01/21/2020 11:06:34 AM

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-MONTEVIDEO CENTERFACILITY NUMBER:
070210990
ADMINISTRATOR:DELUSSA, JENNIFERFACILITY TYPE:
840
ADDRESS:13000 BROADMOOR DRIVETELEPHONE:
(925) 552-4487
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:120CENSUS: 10DATE:
01/21/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Isabel JarvisTIME COMPLETED:
11:10 AM
NARRATIVE
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LPA Dayna Collier met with Assistant Site Director Isabel Jarvis for a case management inspection as a result of receiving an unusual incident report. An incident occurred when a substitute staff member violated a child's personal rights by causing humiliation while the child was using the bathroom. When the child's parent arrived, the child was crying and embarrassed. As a result of the incident, administrative action was taken against the substitute staff member.

The attached type B deficiency is cited today and must be corrected by the due date. This report must be available for public review for 3 years. An exit interview was conducted and the report was discussed. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and the signature on this form acknowledges receipt of these rights.

A site visit notice was posted by staff.
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2020
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-MONTEVIDEO CENTER
FACILITY NUMBER: 070210990
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/28/2020
Section Cited

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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature.
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This requirement was not met as evidenced by report review and interviews conducted. This poses a potential risk to children in care.
A SUBSTITUTE STAFF MEMBER VIOLATED A CHILD'S PERSONAL RIGHTS BY CAUSING THE CHILD HUMILIATION.
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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: Diane PerezTELEPHONE: (510) 622-2590
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: (510) 725-7021
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2020
LIC809 (FAS) - (06/04)
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