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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444408785
Report Date: 11/21/2023
Date Signed: 11/21/2023 11:04:18 AM


Document Has Been Signed on 11/21/2023 11:04 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:CKC CHILDREN'S CENTERFACILITY NUMBER:
444408785
ADMINISTRATOR:TINA BURCHERFACILITY TYPE:
850
ADDRESS:8005 WINKLE AVENUETELEPHONE:
(831) 475-6587
CITY:SANTA CRUZSTATE: CAZIP CODE:
95065
CAPACITY:42CENSUS: 22DATE:
11/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Tina Burcher & Kylie RobertsTIME COMPLETED:
11:23 AM
NARRATIVE
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Licensing Program Analyst (LPA), Cortney Nelson, met with Site Director, Tina Burcher, and Executive Director, Kylie Roberts, and explained purpose of visit. Upon arrival, LPA was admitted into the facility by a staff member.

LPA was notified of an incident that occurred on 11/14/2023, where a child's location was unknown during pick-up time. The child was located outside after approximately one minute and it was determined the child ran out the door that was propped open during pick-up time. The incident was not reported to the Department.

LPA reminded the Executive Director, Kylie Roberts, of the reporting requirements for any instance of lack/absence of supervision involving children in care. Initial reports must be made within 24 hours following the incident occurrence and a written report (LIC624) shall be submitted within seven days.

As a result of today's inspection, a deficiency was cited, see LIC809-D.

Exit interview conducted and the report was reviewed with the Executive Director, Kylie Roberts.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
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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Document Has Been Signed on 11/21/2023 11:04 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: CKC CHILDREN'S CENTER
FACILITY NUMBER: 444408785

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2023
Section Cited
CCR
101212(d)

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101212 Reporting Requirements (d) Upon the occurrence... a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report...shall be submitted to the Department within seven days..

This requirement was not met as evidenced by:
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The Licensee will submit written report for the incident that occurred on 11/14/2023 and submit to the Department by 11/29/2023.
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The Licensee did not notify the Department or submit a written report regarding a absense of supervision for a child on 11/14/2023, which poses a potential risk to the health, safety, and personal rights of 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: Joel SeguraTELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney NelsonTELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2023
LIC809 (FAS) - (06/04)
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