430709735-12-10-2019-07-CC-AALZ-BJR33A-20191210165313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 430709735
Report Date: 12/10/2019
Date Signed: 12/10/2019 04:53:22 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:	CDC - GRAYSTONE		FACILITY NUMBER:	430709735
ADMINISTRATOR:	KRISTINA SMITH		FACILITY TYPE:	840
ADDRESS:	6982 SHEARWATER DRIVE		TELEPHONE:	(408) 997-1980
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95120
CAPACITY:	105	CENSUS: 48	DATE:	12/10/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:08 PM
MET WITH:	Smith, Kristina		TIME COMPLETED:	05:05 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	An unannounced Annual Random Inspection was conducted on this day, by Licensing Program Analyst (LPA) Almaraz, Araceli. Facility is currently licensed for a capacity of 108. Licensing staff met with Director Smith, Kristina. The program currently operates 6:30 AM to 6:00 PM Monday thru Friday. Licensing staff was taken on a guided tour of the facility of both indoors and outdoors. At the initial start of this visit, there was a total census of 48 school aged children and a total census of 6 staff present. PHYSICAL PLANT This is a school aged program which consists of 3 classrooms total; All areas identified on the Facility Sketch were inspected by LPA. Two of the classrooms, A/B(35/36) is a split portable. Room K (37) can be used only when preschool component is not using this room. Currently the preschool component is inactive until further notice. There are no children enrolled in preschool program. Classrooms: The following was observed on the rooms during this visit: Room A (36): There was one teacher and one aide with 21 school-age children, age 3rd to 5th grade. Teacher and child ratios were observed and staff names recorded. There is one toilet, two sinks, located inside of the classroom. Room B (35) There was one teacher, one aide with 19 school-age children, 1st and 2nd grade Teacher and child ratios were observed and staff names recorded. There is one toilet, two sinks, one facet located inside of the classroom. Room K (37) There was one teacher, with 8 school-age children, kindergarten age. Teacher and child ratios were observed and staff names recorded. There are two toilets with no stalls. Director Smith states this design is because the room was originally used for preschool age children. The children are to use the bathroom one by one. Director states there is no more than ten children in this room at any point. There are three sinks, one facet located inside of the classroom. There is a pet turtle in this room, inside of an aquarium. The following is summary of the rooms inspected: Furniture and equipment were inspected for age appropriateness and are in sufficient condition. Telephone service, heating, lighting and ventilation were evaluated. Children have their own cubby to store their belongings. Page 1*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2019

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

FACILITY NAME: CDC - GRAYSTONE	FACILITY NUMBER: 430709735
	VISIT DATE: 12/10/2019

NARRATIVE

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Per director, isolation area is in the office. General sanitation was observed. Availability of indoor drinking water was observed in classrooms. Disinfectants, cleaning solutions, medication and other hazardous items that pose a risk to children, were inaccessible to the children in care. Director Smith states that poisons are locked in kitchen cabinet. All storage containers for solid waste, including moveable trash receptacles have tight-fitting covers that are kept on, and in standard condition. Director states waste is to be discarded immediately after each meal. First Aid supplies were observed in the classroom in backpacks. According to Director Smith, medication is only administered to a child when accompanied with a doctor's note and is stored in the kitchen. Carbon monoxide detectors and smoke detectors are present and working in the facility. There are a total of three Fire extinguishers size 3A40BC in each class room and were serviced on 01/04/2019. Menus posted monthly, available upon request for up to one year. Breakfast and PM snacks provided. Menus posted. Food inspected for quantity and availability.
Outdoor: Outdoor equipment was inspected for safety, cushioning material, good repair and appropriateness. Required shade, drinking water and fencing were inspected. LPA Almaraz advised Director Smith that the children need to be within the direct care and supervision, including visual supervision of the teacher(s) at all times. The children have access to drinking fountains during outside play. Play area was inspected for hazards and inaccessibility to bodies of water; no bodies of water or hazards observed. There are two playgrounds shared with the school district. One play ground is used for kindergarten age children. The second play ground is used for 1st through 5th grade.

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

Care and supervision was evaluated to determine if the basic needs of children are met and appropriate Personal Rights of children were observed by LPA Almaraz.
Facility Records: Sign-in and out sheets and procedures were reviewed. There is a current roster. Last fire drill log 11/14/2019. Staff and Children’s Records were reviewed. Criminal Record Clearances were reviewed for adults. Inspection of required forms made. Page 2*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2019

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: CDC - GRAYSTONE	FACILITY NUMBER: 430709735
	VISIT DATE: 12/10/2019

NARRATIVE

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The following was discussed with Director Smith: Rooms that are off-limits need to be made inaccessible during operating hours. Smoking is prohibited. No infant walkers, no Johnny Jumpers, no excersaucers or any other item that falls into that category are allowed in facility. The Director was advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed. LPA also provided a complete packet of the Provider Information Network (PIN) 10-02-CCP dated February 20, 2019 regarding Safe Sleep Awareness Campaign during today’s inspection.

The fire extinguishers must be 2A40BC or larger and must serviced annually or as often as necessary. Smoke and Carbon Monoxide detectors should be checked and batteries replaced as needed. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your location. Mandatory Forms for the children’s files and staff files, requirements for fire drills, earthquake drills and documentation were discussed. Role and responsibilities of being a Mandated Reporter were reviewed. The Director was advised how to access forms and Regulations online at www.ccld.ca.gov. Director was made aware that it is his/her responsibility to know the regulations as well as anyone who assists in providing care.

LPA advised Director that all adults 18 years of age and older providing Care & Supervision and/or have continuous presence in the facility shall adhere to a criminal background clearance with the Department of Justice, FBI and Child Abuse Index Check. LPA informed Director to log onto web site www.ccld.ca.gov to obtain forms and LIVE SCAN application. Records for all children and staff must be maintained for three (3) years after separation from the facility. The Director was also advised of the requirement to report Unusual Incidents and/or injuries to the parent/guardian and to CCL within the time frame specified by the regulation. Director advised to visit www.shotsforschool.org for immunization information.
Director advised that indoor and outdoor supervision required at all times. If outdoor area not adequately fenced, provider must be with children at all times when outdoors. These forms may also be downloaded from our website: www.ccld.ca.gov
There were no deficiencies cited during today's visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1
NOTICE OF SITE VISIT ISSUED AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS
Exit interview conducted, copy of report was given. Page 3*****

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli Almaraz	TELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2019

LIC809 (FAS) - (06/04)

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