073402672-11-18-2022-52-CC-MPRE-CLAUNX-20221118144441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073402672
Report Date: 11/18/2022
Date Signed: 11/18/2022 02:44:50 PM

Document Has Been Signed on 11/18/2022 02:44 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME:	SRVSACCA - KIDS' COUNTRY AT COYOTE CREEK SCHOOL		FACILITY NUMBER:	073402672
ADMINISTRATOR:	RYAN GIPSON		FACILITY TYPE:	840
ADDRESS:	8700 NORTH GALE RIDGE ROAD		TELEPHONE:	(925) 552-4485
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94582
CAPACITY:	170	CENSUS: 22	DATE:	11/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Ryan Gipson		TIME COMPLETED:	02:45 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 11/18/2022 at 12:35pm Licensing Program Analyst (LPA) Morgan Pringle met with Director Ryan Gipson for an Unannounced Annual Inspection. Three (3) classroom, Room One (1), Room Two (2) and Room Three (3), were toured for a health and safety inspection. There were Twenty-two (22) school age children and four (4) teachers present during the inspection. The facility operates from 7:00am – 6:30pm. The facility is located in the far right building of the Coyote Creek Elementary School.

The facility has age appropriate materials in all three (3) classrooms that are observed to be clean, and in good condition. The outside play yard is fully fenced, clean, and free from hazards with plenty of shade. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. There are four bathrooms that are clean and in proper working order. The kitchen is clean, free from defects and all hazards are made inaccessible to the children in care. All food at the facility is properly stored and labeled. All food brought from the children’s home are labeled. All medications are properly stored and documented. All children have access to clean drinking water in and outside. There are carbon monoxide and smoke detectors on site and a fully charged fire extinguisher on site. LPA did not observe any harmful or unattended bodies of water in or around the facility. There are three (3) animals at the facility. One (1) bearded dragon in Room 1, one (1) bearded dragon in Room 2, and one (1) small tortoise in Room 3. The bearded dragons are housed in locked terrariums and the tortoise is accessible to the children, but Director states that children are not allowed to touch the tortoise without a teacher present.

The facility is operating within its licensed capacity and is in ratio. All proper postings including the facility menu are made visible by the front door of each classroom. The fire/disaster drill log was complete with the last drill logged 11/11/2022. A physical census of the children and staff was taken and cross referenced with the sign-in and out log. All children were properly signed in and accounted for. All staff/adults on site have obtained a criminal record clearance. LPA obtained a sample of the children’s files and staff files. All files were complete and up to date. Continued on LIC809-C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

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 3

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 AT COYOTE CREEK SCHOOL	FACILITY NUMBER: 073402672
	VISIT DATE: 11/18/2022

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
26
27
28
29
30
31
32

Director was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Personnel Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. Director was reminded that California Law requires all facilities to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Director that all forms can be downloaded at www.ccld.ca.gov. Director was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.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.

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Continued on LIC809-C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 AT COYOTE CREEK SCHOOL	FACILITY NUMBER: 073402672
	VISIT DATE: 11/18/2022

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
26
27
28
29
30
31
32

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Director Ryan Gipson.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3