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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070211541
Report Date: 05/31/2019
Date Signed: 05/31/2019 02:19:01 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SRVSACCA - KIDS COUNTRY-GREEN VALLEY CENTERFACILITY NUMBER:
070211541
ADMINISTRATOR:HO, KIVAFACILITY TYPE:
840
ADDRESS:1001 DIABLO ROADTELEPHONE:
(925) 820-3646
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:87CENSUS: 12DATE:
05/31/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kiva HoTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced Annual/Random inspection. There were 5 staff and 12 children present during the inspection. Furniture and equipment was observed to be in good condition, free of sharp, loose, or pointed parts. 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 were free of tripping hazards. The kitchen/food preparation and storage areas were observed to be clean and free of evidence of rodents. Food is protected against contamination. Drinking water is available both indoors and outdoors. Menus are posted and visible for parents to review. There are no pools or similar bodies of water at this facility.

The facility is operating within its licensed capacity. The facility is within ratio today with one 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. A physical census was taken of all children present and crossed referenced with the sign in and out sheets.

The director understands that prior to working or volunteering in a licensed child care facility, all individuals subject to criminal record review shall obtain a clearance or criminal record exemption.

A sample of children’s records were reviewed. Files reviewed contained emergency information. Staff records reviewed have required health screening.

Fire/Disaster drill are conducted monthly.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie AcostaTELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019
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 2
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-GREEN VALLEY CENTER
FACILITY NUMBER: 070211541
VISIT DATE: 05/31/2019
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The facility has updated the plan of operation to include incidental medical services (IMS).

The director was encouraged to 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.

Exit interview conducted with Kiva Ho.

Director was provided a copy of the appeal rights.

Notice of Site visit was provided at the time of inspection, and must be posted for 30 days.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie AcostaTELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019
LIC809 (FAS) - (06/04)
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