434408743-9-22-2021-07-CC-PHEZ-C74PPB-20210922112917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434408743
Report Date: 09/22/2021
Date Signed: 09/22/2021 11:29:31 AM

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:	CATALYST KIDS - TRACE		FACILITY NUMBER:	434408743
ADMINISTRATOR:	ANGELIQUE TORNO		FACILITY TYPE:	840
ADDRESS:	651 DANA AVENUE		TELEPHONE:	(408) 278-1876
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95126
CAPACITY:	70	CENSUS: 0	DATE:	09/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Imelda Liorin		TIME COMPLETED:	11:30 AM

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	Licensing Program Analyst (LPA) Pete Hernandez, conducted an unannounced Required 1 Year inspection to the Facility today. LPA met with Site Supervisor,Imelda Liorin , and explained the nature of today's inspection to her. LPA observed no children in rooms 50 and 51 today with the Site Supervisor because this is an after school program. Ms. Llorin stated that they no longer use Room K-2. LPA toured the Facility both inside and outside during today's inspection. 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, and Activity Schedule. A review of staff records indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded Ms. Llorin of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violations within a 12-month period. LPA reviewed seven (7) children's and four (1) staff (director, 3 teachers) files during today's inspection. Each child's file reviewed contains a version of the Information and Emergency Information form (LIC 700), Parents Rights form (LIC995), Personal Rights form (LIC613), and Consent for Emergency Medical Treatment (LIC627). All four staff files reviewed contain the required transcripts/verification of experience, immunization's against Measles, Pertussis, and Influenza (or an opt out statement), and the Mandated Reporter Training (AB1207). The Site Administrator's CPR and First Aid certifications are current and expires 10/22/2022. Facility Evaluation Report dated 09/22/2021 to be continued on next page:

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

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: CATALYST KIDS - TRACE	FACILITY NUMBER: 434408743
	VISIT DATE: 09/22/2021

NARRATIVE

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Facility Evaluation Report dated 09/22/2021 to be continued from previous page:
LPA observed that two of the Teachers have a current CPR and First Aid certification, and are on site at all times or present during off-site activities (field trips).
The school age program is located at Trace Elementary School site. Since the program is operated at a functioning elementary school site, the facility is exempt from the indoor measurement and outdoor square footage requirements, the fencing requirements, toilet/sink ratios and isolation area requirements. Ms. Llorin understands the conditions, limitations, and capacity specifications of the Facility license.
LPA observed that all rooms are clean and safe for all children and staff. Ms. Llorin stated that the Facility has a third-party cleaning service that cleans the Facility Monday through Friday in the evenings. Drinking water is readily available for the children in each room via the sink with disposable cups and a water fountain. Outdoor playground area water is available via drinking fountains. LPA observed solid waste containers with tight-fitting lids in each room. Children's bathroom is located in Room 50 and is clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children located in Room 51. Ms. Llorin states that there are no weapons or firearms on the premises.
The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. Cleaning supplies are inaccessible to the children and stored in cabinets inaccessible to children.
LPA observed all furniture and equipment is in good condition and safe for the children. Each room has a fully charged regulation fire extinguisher and functioning Carbon Monoxide detectors with working smoke detectors and fire pull stations.
The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. There are sufficient resilient materials in the outdoor playground area. Trees and a canopy are used for shade. LPA did not observe any bodies of water.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

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: CATALYST KIDS - TRACE	FACILITY NUMBER: 434408743
	VISIT DATE: 09/22/2021

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TYPE A language: Should there ever be issuance of Type A citations today, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with the Licensee. A copy of this report and appeals rights were discussed and left with the Licensee, Imelda Llorin, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 334-2151
LICENSING EVALUATOR NAME: Pietro Hernandez	TELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021

LIC809 (FAS) - (06/04)

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