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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410630
Report Date: 06/02/2022
Date Signed: 06/02/2022 01:00:04 PM


Document Has Been Signed on 06/02/2022 01:00 PM - It Cannot Be Edited

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 @ SAN MARTIN GWINNFACILITY NUMBER:
434410630
ADMINISTRATOR:JENNELL CASTILLOFACILITY TYPE:
850
ADDRESS:13745 LLAGAS AVENUETELEPHONE:
(408) 843-9000
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY:24CENSUS: 8DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Erika Becerra GaribayTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA), Deanna Villagrana, conducted an unannounced required one year inspection to the Facility today. LPA met with assistant Erika Becerra Garibay and explained the nature of today's visit to her. Director Janelle Castillo is out for the week and teachers Lorena Rodriguez and Brittany Martinez (Ajluni) are in charge with the assistance of Erika. The Facility is licensed in room 1 and 2 of RO San Martin Gwinn Elementary and is from 8:30am-11:30am. The playground area of the Facility is located between room 1 and 2 and the back of the classrooms. There are not active waivers at this time.

LPA toured the Facility both inside and outside for 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, Menus, and Activity Schedule.

A review of staff records on 05/06/2022 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions Assistant Erika Becerra Garibay was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.


LPA reviewed eight children's and three staff (2 teachers and 1 assistant) files during today's inspection. Teacher Lorena Rodriguez and assistant Erika Becerra Garibay need to update their Mandated Reporter Certificates. Child 1 and 5 are missing LIC701. Two teachers have current CPR and First Aid certifications on file. Staff files (2 teachers) reviewed contain the required transcripts/verification of experience. Erika 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).
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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 @ SAN MARTIN GWINN
FACILITY NUMBER: 434410630
VISIT DATE: 06/02/2022
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LPA observed that the teacher/child ratio was in compliance during today's visit. LPA observed eight preschool children with two teachers and one assistant in room 1. Room 2 is for school age program only. Erika understands the conditions, limitations, and capacity specifications of the Facility license. Erika understands that children shall be visually supervised at all times. LPA observed that room is clean and safe for all children and staff. Erika states that the Facility is cleaned daily by and outside janitorial service. Drinking water is readily available for the children in each room and in the outdoor playground area via water dispenser/disposable cups. LPA observed solid waste containers with tight-fitting lids in the Facility. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff toilet not utilized by the children which an isolated child can use if needed. Erika 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. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. Cleaning supplies are inaccessible to the children and stored in high cabinets inaccessible to children. Any poisons are stored in locked storage cabinets. Any medications at the Facility are stored in the kitchen top cabinet in a locked box. No IMS is administered by the Facility.

LPA observed all furniture and equipment is in good condition and safe for the children. 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. Several tarps and the building overhang provide shade for the day care children. LPA did not observe any bodies of water.

Exit interview conducted and report was reviewed with the assistant Erika Becerra Garibay.


The following type B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies 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.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
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 @ SAN MARTIN GWINN
FACILITY NUMBER: 434410630
VISIT DATE: 06/02/2022
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A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Deanna VillagranaTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/02/2022 01:00 PM - It Cannot Be Edited

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 @ SAN MARTIN GWINN
FACILITY NUMBER: 434410630

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Teacher Lorena Rodriguez and assistant Erika Becerra Garibay need to update their Mandated Reporter Certificates which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2022
Plan of Correction
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Facility will submit a current Mandated Reporter Certificate for teacher Lorena Rodriguez and assistant Erika Becerra Garibay to CCLD by POC date.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Child 1 and 5 are missing LIC701 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/16/2022
Plan of Correction
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Facility will submit LIC701 for child 1 and 5 to CCLD by POC date.

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: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4