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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070212841
Report Date: 02/09/2023
Date Signed: 02/14/2023 12:23:57 PM


Document Has Been Signed on 02/14/2023 12:23 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:SHICHIDA, DANAFACILITY TYPE:
840
ADDRESS:2200 HOLBROOK DRIVETELEPHONE:
(925) 736-3638
CITY:DANVILLESTATE: CAZIP CODE:
94506
CAPACITY:147CENSUS: 26DATE:
02/09/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Dana ShichidaTIME COMPLETED:
02:15 PM
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On 2/9/23 at 1:45 pm Licensing Program Analyst LPA Monica Mathur conducted an unannounced Plan of Correction inspection at SRVSACCA Kids Country - Sycamore Center. LPA met with Director, Dana Shichida and explained purpose of visit. Present in the facility were 26 children and 8 staff.

On 2/1/23 facility self reported an unusual incident of staff roughly mishandling a child during outdoor activity time. On 2/2/23 Facility was cited a Type A deficiency for violation of Personal Rights. Director submitted Plan of Corrections which included written statement of understanding and interpretation of cited regulations, plan on how facility will come back into compliance, conducted all staff training on Personal Rights.

During today's inspection LPA discussed all that has been done to become compliant. Director explained they have had discussions with staff on Personal Rights, systems and procedures have been put in place on how best to implement regulations, standard for outdoor and indoor supervision. LPA observed 809 report of 2/2/23 posted at entrance and Director states report has been provided to all parents. Citation was cleared today and Letter of Clearance provided.

No deficiency was cited today. This report was reviewed with Director, Dana Shichida. NOTICE OF SITE VISIT WAS PROVIDED, MUST BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Monica MathurTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
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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