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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444416685
Report Date: 04/08/2021
Date Signed: 06/28/2021 03:46:22 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:SECRET GARDEN PRESCHOOL, THEFACILITY NUMBER:
444416685
ADMINISTRATOR:HOLLIS DELANCEYFACILITY TYPE:
850
ADDRESS:26 FLORIDO AVENUETELEPHONE:
(801) 652-4417
CITY:LA SELVA BEACHSTATE: CAZIP CODE:
95076
CAPACITY:39CENSUS: DATE:
04/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Olesya Kalinowska TIME COMPLETED:
03:00 PM
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Licensing Program Analysts (LPA) Stephanie Collins conducted announced Tele-Case Management inspection via video conference call with owner Olesya Kalinowske. Due to COVID-19 situation and "Shelter in Place" Order. This LIC809 Facility Evaluation Report will be emailed to the facility. Facility’s reply to the email will serve as acknowledgement that the report was received.

LPA S.Collins met with Administrator Olesya Kalinowska and stated the nature of the Case management Tele-conference regarding an incident that occurred at the facility on 4/6/202. the incident was also reported on 4/7/2021 to CCL by Director Prosch, Lisa The incident was between two minor children.

Facility Roster, Sign in and out sheet was requested they were current. (On file)

LPA interviewed both children involved in the incident. LPA interviewed the two (2) teachers that were supervising 11 children during recess regarding their observations at the facility during recess on 4/6/2021. (See LIC 812)

Based on record review and interviews conducted a lack of supervision did not occur which could have lead to the alleged incident.

No citation issued. Notice of Site Visit issued and must be posted for 30 days.























SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Stephanie CollinsTELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021
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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