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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405019
Report Date: 11/06/2019
Date Signed: 11/06/2019 04:13:29 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CREEK, A MIDDLE SCHOOL YOUTH CENTER, THEFACILITY NUMBER:
073405019
ADMINISTRATOR:DERMODY, COLLEEN MFACILITY TYPE:
840
ADDRESS:2775 CEDRO LANETELEPHONE:
(925) 934-3324
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:100CENSUS: DATE:
11/06/2019
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
03:29 PM
MET WITH:TIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analyst, met with Assistant Director, S. Schiller, for the purpose of a Required 3 year visit. LPA conducted a prior visit to the facility in August 2019, however, CCLD's computer system did not capture the visit and the facility file could not be located to verify visit. LPA spoke with Director, Ms. Colleen, by phone and confirmed our visit. Ms. Colleen will send LPA a copy of report upon her return.
Today, LPA will not review files today. Today, there are 45 children present and four staff present.
Upon arrival to the facility, LPA observed two male children, playing with a rope on a tree in the front of the facility, without the supervision of a staff member. A staff member was standing at the door on the left side of the facility as one enters the facility, and the front door to the facility was closed preventing the staff members from supervising the children in the front. The Assistant Director, stated that children usually play on the other tree in sight of the teacher. Today, the facility will receive a TYPE A Deficiency for lack of supervision. see 809-d. Each parent of children in care and future parents for the next 1 year, shall receive a copy of this report. Parent's shall sign an Acknowledgment of Receipt of Licensing Report LIC9224 and this form shall be placed in children's files. PLEASE SEE 809-D FOR TYPE A VIOLATION
SUPERVISOR'S NAME: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2019
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: CREEK, A MIDDLE SCHOOL YOUTH CENTER, THE
FACILITY NUMBER: 073405019
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2019
Section Cited

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101229a-1 The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. THIS REQUIREMENT WAS NOT MET TODAY.
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Children were playing in the front of the facility without the supervision of staff member's, putting children at immediate risk.
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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: Anika EvansTELEPHONE: (510) 286-4350
LICENSING EVALUATOR NAME: Ronda HollieTELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2019
LIC809 (FAS) - (06/04)
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