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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 350710320
Report Date: 05/11/2021
Date Signed: 05/11/2021 03:01:54 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:GO KIDS CLUB - RO HARDINFACILITY NUMBER:
350710320
ADMINISTRATOR:MITSY NAVARROFACILITY TYPE:
840
ADDRESS:761 SOUTH STREETTELEPHONE:
(831) 636-8171
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:56CENSUS: 19DATE:
05/11/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:26 PM
MET WITH:Mitsy NavarroTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with Director Mitsy Navarro via Facetime due to Covid-19, to deliver findings a complaint. LPA explained the nature of the visit to her. LPA observed 10 children with one teacher Ms. Viridiana in Room 2 and 9 children with one teacher, Miss Linda in the outside playground.

LPA conducted interviews for complaint investigation on 05/04/2021. During the interview process, LPA was made aware that children are allowed to use the restroom without supervision and do not need to inform staff when they need to go.

The following type B deficiency was cited on the attached page (809-D). Director was informed that failure to correct the deficiency by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Notice of site visit was issued and must be posted for 30 days.



This report has been emailed to Director and Director will reply to the email in lieu of a signature.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
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: GO KIDS CLUB - RO HARDIN
FACILITY NUMBER: 350710320
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2021
Section Cited

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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.
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This requirement was not met as evidenced by children are allowed to use the restroom without supervision and do not need to inform staff when they need to go. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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LPA by 05/14/2021.

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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: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2021
LIC809 (FAS) - (06/04)
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