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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444410610
Report Date: 12/15/2020
Date Signed: 03/17/2021 08:11:16 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:COMMUNITY BRIDGES FAIRGROUNDS CHILD DEV CENTERFACILITY NUMBER:
444410610
ADMINISTRATOR:AMY RATHERFACILITY TYPE:
850
ADDRESS:2667 EAST LAKE AVENUETELEPHONE:
(831) 786-9621
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY:45CENSUS: 6DATE:
12/15/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Amy RatherTIME COMPLETED:
01:00 PM
NARRATIVE
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A follow up virtual visit conducted with Amy Rather, Site Supervisor via Zoom. Purpose of the visit is to clarify some information perviously provided with Amy and to deliver the finding of the investigation regarding a self reported incident where a child walked home alone without staff knowledge.
Please see next page for violation cited under Title 22. .
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020
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: COMMUNITY BRIDGES FAIRGROUNDS CHILD DEV CENTER
FACILITY NUMBER: 444410610
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2020
Section Cited

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Responsibility for Providing Care and Supervision- Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). This requirement was not met as evidence by:
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a self reported incident occurred on 11/13/20. A child walked home without staff knowledge, parent called facility to notify the center. This pose an immediate risk to health and safety 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: Anthony StudebakerTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Mahvash BehboodTELEPHONE: (408) 334-8552
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2020
LIC809 (FAS) - (06/04)
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