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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440710304
Report Date: 08/14/2019
Date Signed: 08/14/2019 04:16:29 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: 73DATE:
08/14/2019
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Gabriel GonzalesTIME COMPLETED:
04:30 PM
NARRATIVE
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An unannounced visit was made by analyst Behbood to inspect the correction of citations issued during annual visit on 07/12/19.
The following was checked;
IMS plan of operation was not prepared due to lack of understanding, so Analyst explained in details of what is required to be in IMS Plan of operation so this citation is not corrected.
A sample of staff files reviewed and they appear to be in order. This citation is corrected.
Bathroom was inspected and again on the toilet seat were urine. This citation is not corrected. The refrigerator was cleaner than it use to be.
Garbage can with lid was observed in the classroom- This citation is corrected.
Please see next page for recitation of the uncorrected violations. Licensee understand failure to correct them in a timely manner will result in civil penalty.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
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
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: 08/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2019
Section Cited
CCR
011173(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 failed to correct this citation so the due date is extended.
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Will submit the plan for approval. This must be completed no later than 08/281/9.
Type B
08/28/2019
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 and freezer wasn't clean statisfactory and the toilet seat had urine all over it. This is the bathroom used by boys and girls.

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Plan of correction must be recieved by 08/28/19.
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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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
LIC809 (FAS) - (06/04)
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