070210990-8-11-2021-52-CC-MOTI-C5SUL5-20210811154011

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 070210990
Report Date: 08/11/2021
Date Signed: 08/11/2021 03:40:17 PM

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 CENTER		FACILITY NUMBER:	070210990
ADMINISTRATOR:	DELUSSA, JENNIFER		FACILITY TYPE:	840
ADDRESS:	13000 BROADMOOR DRIVE		TELEPHONE:	(925) 552-4487
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	120	CENSUS: 57	DATE:	08/11/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Danielle Sams		TIME COMPLETED:	04:00 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 Visit was conducted on this date 8/11/2021 by Licensing Program Analyst (LPA) Melanie Otsuji. LPA met with Director, Dani Sams. An application was submitted for an Addition of Room. The center has requested to add ROOM A as TEMPORARY licensed space. The school age program is located on Montevideo Elementary School campus. The program is currently utilizing Room P5 (previously known as P1) and the MULTI PURPOSE ROOM on school grounds. Hours of operation are from 7:00AM to 6:30PM, Monday through Friday. Present today were 7 staff members and 57 children. A health and safety inspection was conducted inside and outside. INDOORS: EXEMPT OUTDOORS: EXEMPT Facility utilizes Montevideo Elementary School playground and blacktop. 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. Lunch is brought from home. 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. All licensing required documents are posted.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Melanie Otsuji	TELEPHONE: (510) 622-2613
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

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
	VISIT DATE: 08/11/2021

NARRATIVE

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Per Director, all Opening and Closing staff have current Pediatric CPR/First Aid. Playground equipment is in good condition. This facility plans to provide Individual 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 of the temporary addition of Room A will be issued pending receipt of Fire Clearance.

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: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC809 (FAS) - (06/04)

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