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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410631
Report Date: 08/19/2021
Date Signed: 08/19/2021 03:52:07 PM

Document Has Been Signed on 08/19/2021 03:52 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: 18DATE:
08/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Jennell CastilloTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Deanna Villagrana met with Director Jennell Castillo for an unannounced case management inspection. Purpose of today's inspection is to address an Unusual Incident that the Facility self reported to Community Care Licensing (CCL) on 08/04/2021. LPA observed 10 children with one teacher and one aide in classroom 1 and eight children with one teacher in classroom two.

LPA interviewed Jennell and obtained pertinent documents. Based on information obtained, it was found a child who is allergic to dairy which is noted in child's file on form LIC702 and LIC627, was given dairy products on 07/26/2021 in the form of buttered popcorn. Staff did not realize the butter in the popcorn would cause a reaction. Child did not have a reaction at the school and only showed signs in the evening when child was home.

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

A Notice of Site was issued and must be posted for 30 days.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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 2
Document Has Been Signed on 08/19/2021 03:52 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 08/19/2021 at 03:27 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: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2021
Section Cited
CCR
101223(a)(2)

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To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by a child who is allergic to dairy which is noted in child's file on form LIC702 and LIC627, was given dairy products on 07/26/2021 in the
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Director will meet with the parent to discuss child's allergies and asthma issues and to ensure facility takes proper procedure should they child accidentally have a reaction or asthma attack. Director will submit a letter stating what was discussed to LPA by 09/02/2021.
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form of buttered popcorn. Staff did not realize the butter in the popcorn would cause a reaction.
This poses a potential risk Health, Safety Personal Rights risk 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: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021


LIC809 (FAS) - (06/04)
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