274404880-8-12-2021-07-CC-SCES-C5TSMJ-20210812140000

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 274404880
Report Date: 08/12/2021
Date Signed: 08/12/2021 02:00:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	GREENFIELD USD OAK AVE. PS		FACILITY NUMBER:	274404880
ADMINISTRATOR:	JACQUELINE VALENCIA		FACILITY TYPE:	850
ADDRESS:	1239 OAK AVENUE		TELEPHONE:	(831) 674-2431
CITY:	GREENFIELD	STATE: CA	ZIP CODE:	93927
CAPACITY:	24	CENSUS: 8	DATE:	08/12/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jaqueline Valencia		TIME COMPLETED:	02:10 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 08/12/2021 at 11:30 AM, Licensing Program Analyst (LPA), Susy Cervantes, conducted an unannounced annual visit to the Facility. LPA met with Jaqueline Valencia, Teacher, and explained the nature of today’s visit. LPA toured the Facility both inside and outside during today’s visit. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents’ Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus (includes current and following week), and Activity Schedule. All staff are fingerprinted and cleared by Greenfield Union School District. LPA observed the medical assessment and the Information and Emergency Information form (LIC 700) in 3 children’s files. LPA observed the required health screening in 2 staff files. Teacher has current CPR and First Aid Certifications on file (expiration date: 06/17/2023). Teacher understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips). Teacher understands the conditions, limitations, and capacity specifications of the Facility license. Teacher understands that children shall be visually supervised at all times. LPA observed that the teacher/child ratio was in compliance during today’s visit. LPA observed one teacher and one aide with 8 children during today’s visit. LPA reviewed the sign-in, sign-out sheets for this week, facility had been closed and reopened yesterday (08/11/2021), and Child Care Facility Roster (LIC 9040) and all were in compliance. LPA observed that all rooms are clean and safe for all children and staff. Drinking water is readily available for the children in each room and in the outdoor playground area via water dispensers, drinking fountains are not being used at this time. LPA observed solid waste containers with tight-fitting lids in each room and in the playground area. *Continues on report dated 08/12/2021 pg. 1/2*

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GREENFIELD USD OAK AVE. PS	FACILITY NUMBER: 274404880
	VISIT DATE: 08/12/2021

NARRATIVE

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Continuation of report dated 08/12/2021 pg. 2/2

Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Teacher states that there are no weapons on the premises.

The food is prepared by the Oak Avenue Elementary School where the preschool is located. Cleaning supplies are inaccessible to the children. There are no children with medications at the Facility at this moment, LPA observed the medicine box that is in the classroom and inaccessible to children.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground area is currently bare of play equipment, teacher stated it is under construction, but they bring out toys for the children, LPA did not observe any hazardous items in the outdoor play area. The outdoor play area is surrounded by appropriate fencing. There is also sufficient resilient materials (type: sand) in the outdoor playground area. LPA did not observe any bodies of water.

LPA discussed Zero Tolerance with $500 civil penalty and the requirements of AB633 with the teacher, Jaqueline Valencia and provided them the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and they understand the requirements.

Licensing Forms, Title 22 Regulations and Information can be obtained through the internet at www.cdss.ca.gov. LPA conducted an exit interview with Teacher prior to the conclusion of today’s visit.

No deficiency cited.

NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Susy Cervantes	TELEPHONE: (408) 598-9403
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC809 (FAS) - (06/04)

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