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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440710304
Report Date: 07/12/2019
Date Signed: 07/12/2019 04:41:41 PM

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:CITY OF SCOTTS VALLEY-VINE HILLFACILITY NUMBER:
440710304
ADMINISTRATOR:NICOLE POMPETTEFACILITY TYPE:
840
ADDRESS:151 VINE HILL SCHOOL ROADTELEPHONE:
(831) 438-6529
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:142CENSUS: 50DATE:
07/12/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Gabby GonzalesTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Behbood, conducted an unannounced random visit to the Facility today. LPA met with Gabriel Gonzales, Co-Site Supervisor. Purpose of the visit explained. Present also were 10 staff with 50 children. LPA toured both inside and outside of the facility during today's visit.
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 (PUB 269), Menus (includes current and following week), and Activity Schedule.
All staff have criminal record clearances. No bodies of water observed.
LPA reviewed samples of children's file and sign in and out sheets during today's visit. Each child's file reviewed contains the Information and Emergency Information form (LIC 700) and a copy of the admission agreement. LPA observed that all children were properly signed in and out (legal signature & time of day) by a parent or authorized representative. All staff have current CPR and First Aid certifications on file . Furniture & equipment appear in good condition. Children's bathrooms are in operating condition but needs cleaning.
Playground has climbing structures, Wood chips are used for cushioning material.
Drinking water inside the classrooms provided by water fountain and in the playground via water containe Incidental Medical Services were discussed with the licensee. This facility provides Incidental Medical Services (IMS). LPA reviewed storage of medication and equipment /supplies,
Please see next page for citations under Title 22.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2019
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: CITY OF SCOTTS VALLEY-VINE HILL
FACILITY NUMBER: 440710304
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2019
Section Cited
CCR
101173(c)
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Plan of Operation - Any proposed changes in the plan of operation that affect services to children shall be subject to departmental approval prior to implementation and shall be reported as specified in Section 101212. Facility provides IMS but has not submitted plan of operation for it. This is potentially dangerous to health and safety of children.
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Plan of operation for IMS must be received no later than 08/02/19
Type B
07/12/2019
Section Cited
CCR
101217(a)
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Personnel record - Most of the personnel file reviewed were missing one form or another. This is potentially dangerous to health and safety of children.
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Review all personnel files and complete them no later than 08/02/19.
Type B
08/02/2019
Section Cited
CCR
101238(a)
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Building and Grounds - The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors. refrigerator, freezer and bathrooms were dirty. This is potentially dangerous to health and safety of children.

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Clean the freezer, refrigerator, floor and bathrooms and maintain the cleanliness.
Type B
08/02/2019
Section Cited
CCR
101239(f)(1)
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Fixtures, Furniture, Equipment and Supplies - All containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof. None of the bins had tightfitting cover. This is potentially dangerous to health and safety of children.

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Must be corrected by due date.
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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2019
LIC809 (FAS) - (06/04)
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