434413667-8-13-2019-07-CC-SYIP-BEZPEU-20190813111544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413667
Report Date: 08/13/2019
Date Signed: 08/13/2019 11:15:51 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:	ONE WORLD AFTER SCHOOL-PROGRAM		FACILITY NUMBER:	434413667
ADMINISTRATOR:	MELISSA ALVAREZ		FACILITY TYPE:	840
ADDRESS:	277 IOOF AVE		TELEPHONE:	(408) 460-1797
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	25	CENSUS: 0	DATE:	08/13/2019
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME BEGAN:	09:56 AM
MET WITH:	Melissa Alvarez		TIME COMPLETED:	11:25 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) Samantha Yip conducted unannounced Case Management- Licensee Initiated. LPA met with Melissa Alvarez, Licensee/Director, and explained the reason for inspection. The purpose of the inspection is Licensee is requesting to add Room 15 to their license. Facility is located on Gilroy Prep Academy campus and is currently licensed in Room 12. The hours of operation are Monday, Tuesday, Thursday, Friday 2PM-6PM and Wednesdays 12:30PM -6PM. Present during the inspection was Licensee. There were no day care children present during today's inspection. Staff present during today's inspection have fingerprint clearance. An annual random inspection was conducted on 07/18/2019. An approved fire clearance for Room 15 and Room 12 was granted on 08/09/2019 for 25 children. LPA toured Room 15. The measurements for Room 15 are as followed: 22.833 x 39.333 = 898.090 minus encumbered space 2.167 x 8 = 17.336 898.090 - 17.336= 880.754 Total indoor space: 880.754 divided by 35 = 25 LPA observed there are 37 chairs and 16 tables in Room 15. There is sufficient amount of hooks outside of Room 15 for the children's belongings. LPA observed there is fully charged fire extinguisher and smoke detector. Licensee does have a carbon monoxide detector in Room 12 and does have an additional carbon monoxide detector, which she will be placing in Room 15. -------------continues on 809 dated 08/13/2019 page 2-------------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019

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: ONE WORLD AFTER SCHOOL-PROGRAM	FACILITY NUMBER: 434413667
	VISIT DATE: 08/13/2019

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------------------continuation of 809 dated 08/13/2019 page 1------------------------------------

Licensee stated that they will use the shelf in the back of the room to store supplies for the children in care. LPA discussed with Licensee to ensure that they do not commingle with other programs on campus.

Based on the approved fire clearance capacity and the indoor square footage measurements, the facility physical plant has been approved and an updated license reflecting the request in room change will be issued pending Community Care Licensing Management Approval.

Licensee stated that she submit a letter of permission from Gilroy Prep Academy to use Room 12 and Room 15.

No deficiencies have been cited as a result of this inspection. An exit interview was conducted were this report was discussed to Licensee. A notice of site visit has been issued and must be posted for 30 consecutive days.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019

LIC809 (FAS) - (06/04)

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