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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410631
Report Date: 01/15/2020
Date Signed: 09/14/2021 03:25:31 PM

Document Has Been Signed on 09/14/2021 03:25 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:
434410631
ADMINISTRATOR:LAURA BEHLFACILITY TYPE:
840
ADDRESS:13745 LLAGAS AVENUETELEPHONE:
(408) 843-9000
CITY:SAN MARTINSTATE: CAZIP CODE:
95046
CAPACITY: 60TOTAL ENROLLED CHILDREN: 0CENSUS: 32DATE:
01/15/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Maria SernasTIME COMPLETED:
03:55 PM
NARRATIVE
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*******THIS IS AN AMENDED REPORT THAT SUPERSEDES REPORT DATED 01/15/2020*********

Licensing Program Analyst (LPA), Deanna Villagrana, conducted an unannounced annual/random inspection to the Facility today. LPA met with Maria Sernas, Master Teacher and explained the nature of today's visit to her. Director Laura Behl was away from the facility purchasing supplies. The Facility is licensed in room 1 and 2 at San Martin Gwinn school located in a portable on the south side of the school. The playground area of the Facility is located in front room 1 and 2 of the portables.

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 01/13/2020 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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 ten children's and one teacher assistant files during today's inspection. Maria has a current CPR and First Aid certifications on file which expires 12/08/2020. All staff have immunization on file. Maria 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).
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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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Document is an Amendment of Original Document on 08/23/2021 01:24 PM


Created By: Deanna Villagrana On 01/15/2020 at 03:24 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
CCLD Regional Office, 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: 01/15/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2020
Section Cited
CCR
101516.5(b)

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Teacher-Child Ratio
There shall be a staffing ratio of one teacher and one aide present to every 28 children in attendance.
This requirement was not met as evidenced by LPA observed 19 children with two adults in room 1. Neither adult in room 1 had evidence of completion of the required college course work on file.
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Director shall ensure that all personal files are current and contain required verification for their position.
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This poses an immediate risk to the Health, Safety or Personal Rights to children in care.
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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 Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


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: GO KIDS CLUB @ SAN MARTIN GWINN
FACILITY NUMBER: 434410631
VISIT DATE: 01/15/2020
NARRATIVE
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LPA observed that the teacher/child ratio was not in compliance during today's visit. LPA observed 13 children with one teacher in room 2 and 19 children with two adults in room 1. Neither adults in room 1 had evidence of completion of the required college course work on file. Maria understands that children shall be visually supervised at all times. LPA observed that rooms are clean and safe for all children and staff. Maria states that the Facility staff rotate cleaning and sanitizing toys. The facility is cleaned daily by and outside janitorial service. Drinking water is readily available for the children via water dispenser and plastic 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. Maria 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. Any poisons are stored in locked storage cabinets in the kitchen and staff bathroom. Any medications at the Facility are stored in the kitchen in top cabinet secured in a metal 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. The building overhang provide shade for the day care children. LPA did not observe any bodies of water.


The following Type B deficiency was cited during visit.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FACILITY ENTRANCE, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021
LIC809 (FAS) - (06/04)
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