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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413667
Report Date: 06/08/2022
Date Signed: 06/09/2022 09:13:17 AM


Document Has Been Signed on 06/09/2022 09:13 AM - 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:ONE WORLD AFTER SCHOOL-PROGRAMFACILITY NUMBER:
434413667
ADMINISTRATOR:MELISSA ALVAREZFACILITY TYPE:
840
ADDRESS:277 IOOF AVETELEPHONE:
(408) 460-1797
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:25CENSUS: 11DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:08 PM
MET WITH:Melissa AlvarezTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required-1 Year inspection. Arrived at the facility at 12:08PM, front desk receptionist stated that Licensee is not here yet. LPA met with Licensee Melissa Alvarez at around 12:15PM and explained the reason for the inspection. Children started to arrival around 12:30PM. Present during today's inspection were 11 children and Licensee. Facility was within ratio during today's inspection. LPA observed that children went to the bathroom by themselves while Licensee was in the room. Children were not visually supervised while they were going to the bathroom. LPA discussed with Licensee about children need to be supervised when children are going to the bathroom. Licensee stated that she will stand by the door, so she can visually supervise children going into the bathroom.

There is board to post required postings, such as license, earthquake preparedness checklist, notification of parent's rights, personal rights, and daily schedule. The hours of operation are Monday, Tuesday, Thursday, and Friday from 2PM to 6PM, and Wednesday from 12:30PM to 6PM. Facility is located on the Gilroy Prep School campus in Room 12 and Room 15. Licensee stated that they are currently only using Room 12. LPA reviewed the sign in/sign out sheet.

LPA toured the Rooms. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. There are toys for children. Equipment were observed to be in good condition. LPA reminded Licensee that anything that states to keep out of reach of children needs to be inaccessible, such as Clorax wipes, hand sanitizer, and Windex. Facility uses the bathroom next to Room 11 or girls and boys bathroom around the corner.

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SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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: 06/08/2022
NARRATIVE
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------------------------continuation of 809 dated 06/08/2022 page 1-------------------------------

Licensee stated that there are no weapons, such as firearms, stored on the premise. Licensee stated that fire drill was conducted before spring break, around April 2022, but does not have proof of it. Licensee stated that she will send proof to Licensing.

Facility uses the blacktop area and playground. Area is fenced. Area around play structure has resilient material. Shaded rest area is provided through tree and canopy. There were no bodies of water observed during today's inspection.

Facility only provides snacks to children. Menu was observed to be posted. Facility uses Room 11 to prepare and store snack. Drinking water is provided through water fountain and water jug and cups.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

A copy of facility roster was obtained. Nine children's files were reviewed during today's inspection. The records reviewed include but not limited to notification of parent's rights, consent of emergency medical treatment, and admission agreement. LPA observed that all children did not have LIC 702: Child's Preadmission Health History on file. Licensee stated that she will have all parent fill it out and send proof to Licensing. Licensee stated that the last day that she will open is tomorrow, 06/09/2022. She will be closed for the summer and re-open in the fall school year.


------------------------------continues on 809 dated 06/08/2022 page 3------------------------------
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8
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: 06/08/2022
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-------------------------continuation of 809 dated 06/08/2022 page 2-------------------------------

Licensee's file was reviewed. Licensee completed the Mandated reporter training on 08/13/2020. LPA reminded Licensee that Mandated Reporter training requires renewal every 2 years. Licensee has a valid CPR/1st Aid, which expires on 03/02/2024. Licensee stated that she will submit immunization record for measles, pertussis, and influenza to Licensing.

All adults present have cleared fingerprints. Licensee 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 Samantha Yip informed licensee Melissa Alvarez that this report dated 06/08/2022 document one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha Yip informed the licensee to provide a copy of this licensing report dated 06/07/2022 that documents any Type A citation 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.

As a result of this inspection, one Type A citation, one Type B citation, two technical violations, and one technical assistant was issued. A civil penalty of $500 was assessed for immediate $500. Exit interview conducted and report was reviewed with the licensee, Melissa Alvarez. 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.

SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 06/09/2022 09:13 AM - 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: ONE WORLD AFTER SCHOOL-PROGRAM
FACILITY NUMBER: 434413667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101229(a)(1)
(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
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Based on observation, the licensee did not comply with the section cited above. LPA observed that two children went to bathroom next to Room 11, while Licensee was inside. Licensee was unable to visually supervise children as they went and come back from the bathroom, which posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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By POC 06/09/2022, Licensee stated that she will she submit written plan on how she will visually supervise children at all time including when they are going to the bathroom.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 06/09/2022 09:13 AM - 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: ONE WORLD AFTER SCHOOL-PROGRAM
FACILITY NUMBER: 434413667

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101521(b)
The licensee shall obtain from the child's authorized representative a health background related to the child's ability/inability to participate in center activities.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviews, the licensee did not comply with the section cited above in 9 out of 9 children's file, which poses a potential health, safety or personal rights risk to persons in care. All children did not have child's preadmission health history on file.
POC Due Date: 08/08/2022
Plan of Correction
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Licensee stated that she will have parent fill out form and send proof to Licensing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 8 of 8