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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402672
Report Date: 01/23/2024
Date Signed: 01/23/2024 03:06:26 PM


Document Has Been Signed on 01/23/2024 03:06 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 SCHOOLFACILITY NUMBER:
073402672
ADMINISTRATOR:NINA VICTORIAFACILITY TYPE:
840
ADDRESS:8700 NORTH GALE RIDGE ROADTELEPHONE:
(925) 552-4485
CITY:SAN RAMONSTATE: CAZIP CODE:
94582
CAPACITY:170CENSUS: 19DATE:
01/23/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Swapna KshirsgarTIME COMPLETED:
03:05 PM
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On 1/23/2024 at 12:30pm Licensing Program Analyst (LPA) Morgan Pringle met with facility staff Swapna Kshirsgar for an Unannounced Required - 3 Year Inspection. There were nineteen (19) school age children, and four (4) additional staff present during LPA's inspection. Three (3) classrooms, Room One (1), Room Two (2) and Room Three (3) were toured for a health and safety inspection. The facility is located in the far right building of the Coyote Creek Elementary School. The facility operates from 7:00am – 6:30pm, Monday - Friday.

The facility has ample age-appropriate materials in the classrooms that were observed to be clean and in good condition. All toxins, cleaning products, children’s medication, and hazardous materials were observed to be in inaccessible areas. All medications on site are properly stored and documented. All children’s bathrooms were observed to be clean, well maintained, free of defects with an ample number of sinks and toilets that are in proper working order. LPA observed three (3) animals at the facility. Two (2) bearded dragons in Room 1, and one (1) small tortoise in Room three (3). The bearded dragons are housed in locked terrariums and the tortoise is accessible to the children. Facility staff stated that children are not allowed to touch the tortoise without a teacher present. There are multiple fully charged fire extinguishers, carbon monoxide detectors, smoke detectors, and first aid kits on site. The facility does not transport children.

The kitchen was observed to be clean, well maintained, and free from defects. All hazards are made inaccessible to the children in care. All food on site is properly labeled and stored. Facility only provides snacks for the children. When children are present all day the children will bring their own lunch. All food that will be brought from the children’s home will be properly labeled and stored. All children have access to clean drinking water as well.

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SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/23/2024
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: SRVSACCA - KIDS' COUNTRY AT COYOTE CREEK SCHOOL
FACILITY NUMBER: 073402672
VISIT DATE: 01/23/2024
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The outside play yard is fully fenced with ample age-appropriate materials for the children with ample shade. There are two storage sheds that remain locked making them inaccessible to the children in care. 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 staff working have obtained a criminal record clearance, exemption, or transfer. The fire/disaster drill log is complete with the last drill logged 12/18/2023. A physical census of the children was taken and cross referenced with the sign-in and out log. All children were properly signed in by the facility staff. All required postings, including the menu, are posted by the front door of every classroom. LPA obtained a sample of the children’s files, staff files, and facility files. All files were complete.

No deficiencies were cited during the inspection.

Facility staff was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting https://mandatedreporterca.com/. Personnel and facility roster must be properly maintained, and fire/disaster drills must be conducted at least every six (6) months and documented. Licensee was reminded that California law requires facilities to report unusual incidents and/or injuries to children in care, to the child's parents, and to the Department within 24 hours by phone. Within seven (7) days from the incident, facilities must submit the Unusual Incident/Injury form (LIC 624) to the Department. LPA informed Facility staff that all forms can be downloaded at www.ccld.ca.gov.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.

For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

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SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: SRVSACCA - KIDS' COUNTRY AT COYOTE CREEK SCHOOL
FACILITY NUMBER: 073402672
VISIT DATE: 01/23/2024
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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 PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Facility staff was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Facility staff was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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 facility staff Swapna Kshirsgar.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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