434410631-6-2-2022-07-CC-DVIA-CEZVQF-20220602163816

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434410631
Report Date: 06/02/2022
Date Signed: 06/02/2022 04:38:24 PM

Document Has Been Signed on 06/02/2022 04:38 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 GWINN		FACILITY NUMBER:	434410631
ADMINISTRATOR:	JENNELL CASTILLO		FACILITY TYPE:	840
ADDRESS:	13745 LLAGAS AVENUE		TELEPHONE:	(408) 843-9000
CITY:	SAN MARTIN	STATE: CA	ZIP CODE:	95046
CAPACITY: 60	TOTAL ENROLLED CHILDREN: 60	CENSUS: 17	DATE:	06/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Erika Bacerra Garibay		TIME COMPLETED:	04:45 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	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 at San Martin Gwinn Elementary. The playground area of the Facility is located between room 1 and 2 and the back of the classrooms and a large playground in front of room 1. 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 teacher Lorena Rodriguez 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 ten children's files during today's inspection. All children's files were complete. LPA reviewed staff files during inspection for the preschool on 06/02/2022. Teacher Lorena Rodriguez and assistant Erika Becerra Garibay need to update their Mandated Reporter Certificates. A citation was cited on report for preschool. Two teachers

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
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: 434410631
	VISIT DATE: 06/02/2022

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
26
27
28
29
30
31
32

have current CPR and First Aid certifications on file. Staff files (2 teachers) reviewed contain the required transcripts/verification of experience. Lorena 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).

LPA observed that the teacher/child ratio was in compliance during today's visit. LPA observed 10 children in room 1 with one teacher and one aid and observed seven children in room 2 with one teacher. Lorena understands the conditions, limitations, and capacity specifications of the Facility license. LPA observed two children walk out of room 1 back door and walk to room 2 side door without supervision. LPA observed teacher Lorena open the door after the children had already approached the door. Lorena understands that children shall be visually supervised at all times. LPA observed that rooms are clean and safe for all children and staff. Lorena 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 and are located in room 1. Children are monitored as they walk back in forth from each classroom and teachers communicate by walkie-talkie when children need to use the facility. There is a separate staff toilet not utilized by the children which an isolated child can use if needed. Lorena 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 Lorena Rodriguez.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
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: 434410631
	VISIT DATE: 06/02/2022

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
26
27
28
29
30
31
32

The following type A deficiency was cited on the attached page (809-D). Facility 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.

LPA Deanna Villagrana informed Lorena Rodriguez that this report dated 06/02/2022document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Deanna Villagrana informed the teacher Lorena Rodriguez to provide a copy of this licensing report dated 06/02/2022 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
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 04:38 PM - It Cannot Be Edited

Created By: Deanna Villagrana On 06/02/2022 at 04:12 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GO KIDS CLUB @ SAN MARTIN GWINN	FACILITY NUMBER: 434410631
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

101229(a)(1)

Responsibility For Providing Care and Supervision

(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed two children walk out of room 1 back door and walk to room 2 side door without supervision which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2022
	Plan of Correction
1 2 3 4	LPA spoke to Director Janelle Castillo over the phone during visit. Janelle will submit a statement how the facility plans to supervise children at all times and submit to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Segura

LICENSING EVALUATOR NAME:

Deanna Villagrana

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