070212841-2-2-2023-02-CC-MMAR-CNP2SR-20230202163934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 070212841
Report Date: 02/02/2023
Date Signed: 02/02/2023 04:39:47 PM

Document Has Been Signed on 02/02/2023 04:39 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 (SYCAMORE CENTER)		FACILITY NUMBER:	070212841
ADMINISTRATOR:	FRITZ, ERICA		FACILITY TYPE:	840
ADDRESS:	2200 HOLBROOK DRIVE		TELEPHONE:	(925) 736-3638
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94506
CAPACITY:	147	CENSUS: 42	DATE:	02/02/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Dana Shichida		TIME COMPLETED:	05:00 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	On 2/2/23 at 2:15 pm Licensing Program Analyst (LPA) Monica Mathur conducted a Case Management inspection at SRVSACCA Kids Country Sycamore Center. LPA met with Director, Dana Shichida and explained purpose of today's inspection. On 2/1/23 facility reported to Community Care Licensing an unusual incident that occurred on 1/31/23 where a staff member S1 physically manhandled child C1 in the big playground. Staff and child interviews reveal that while playing outside at around 3:35 pm there was a verbal spat between S1 and C1. S1 got upset with C1, picked C1 up, flung over his shoulders holding C1 by his ankles. C1 was almost completely suspended behind S1's shoulders and back. In interview with C1, child stated S1 flung him over the shoulders and tossed him up in the air and catching him back. C1 stated he was scared, distraught, cried hysterically, begged to be put down but S1 did not do that. C1 stated S1 threatened to throw him through the basketball hoop. There were several other children and staff present who witnessed this incident. S2 heard C1 crying hysterically, and saw C1 over S1's shoulders. S2 ran toward S1, asking him to stop. This violates children's personal rights, and posed an immediate risk to health and safety of C1 and children in care. Type A deficiency is cited on page 809-D under California Code of Regulations CCR 101223(a)(1) and (3) Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights: (1) To be accorded dignity in his/her personal relationships with staff and other persons (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 including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. continued on page 809-C

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SRVSACCA- KIDS COUNTRY (SYCAMORE CENTER)	FACILITY NUMBER: 070212841
	VISIT DATE: 02/02/2023

NARRATIVE

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LPA Mathur informed Director, Dana Shichida that this report dated 2/2/23 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 2/2/23 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 that a Non Compliance Conference will be held soon to discuss deficiency.

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

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/02/2023 04:39 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 (SYCAMORE CENTER)	FACILITY NUMBER: 070212841
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/03/2023 Section Cited	1 2 3 4 5 6 7	101223 Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights (1) To be accorded dignity in his/her personal relationships with staff and other persons (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 including but not limited to [...]. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	By POC Due Date 2/3/23 Director agreed to: 1. submit in writing understanding and interpretation of personal rights regulations. 2. plan to how faciity will be back in compliance 3. By POC Due Date 2/9/23 conduct all staff training, discuss personal rights, best practices, and watch training video on Personal Rights on CCLD website
	8 9 10 11 12 13 14	Per investigation, S1 physically mishandled C1, picked up and flung child over shoulder, tossed up down in the air and threatened to throw C1 into basketball hoop. This incident made C1 cry hysterically, scared and begging to be put down. This poses an immediate risk to health safety of child/ren in care.	8 9 10 11 12 13 14	4. Submit proof of staff training with signed attendance of all staff and agenda discussed.
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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: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica Mathur	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC809 (FAS) - (06/04)

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