073402672-12-1-2021-52-CC-MPRE-C9AVZ9-20211201155222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073402672
Report Date: 12/01/2021
Date Signed: 12/01/2021 03:52:30 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 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: 56	DATE:	12/01/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:33 PM
MET WITH:	Ryan Gipson		TIME COMPLETED:	03:51 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 12/1/2021 at 12:33pm Licensing Program Analyst (LPA) Morgan Pringle met with Director Ryan Gipson for an Unannounced Annual Inspection. Two (2) classroom were toured for a health and safety inspection. There were fifty-six (56) school age children and seven (7) teachers present during the inspection. The facility operates from 7:00am – 6:30pm. The facility is licensed for three (3) classrooms. The third classroom is currently being repaired.

The facility has age appropriate materials in the classroom that are observed to be clean and in good condition. The outdoor space has ample shade for the children and age appropriate materials. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. All medications are properly stored and documented. All sinks are observed to be clean and in proper working order. All children have access to clean drinking water in the classroom and outside as well. LPA did not observe any harmful or unattended bodies of water in or around the facility.

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 10/21/2021 and 11/30/2021. 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. 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: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRVSACCA - KIDS' COUNTRY AT COYOTE CREEK SCHOOL	FACILITY NUMBER: 073402672
	VISIT DATE: 12/01/2021

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.

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.

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/inspection-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: 12/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2