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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407406
Report Date: 11/05/2021
Date Signed: 11/05/2021 12:49:20 PM

Document Has Been Signed on 11/05/2021 12:49 PM - 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:KIDS FIRST ACADEMYFACILITY NUMBER:
073407406
ADMINISTRATOR:GUEVARA, AMELITAFACILITY TYPE:
850
ADDRESS:2430 WILLOW PASS RD., STE 111TELEPHONE:
(925) 709-5437
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY: 38TOTAL ENROLLED CHILDREN: 20CENSUS: 13DATE:
11/05/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Monica BarcenaTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Diana Campos conducted an unannounced case management visit. LPA met with Operations Manager Monica Barcena to investigate a complaint. During the complaint investigation it was discovered that facility had not reported unusual incidents on more than one occasion. Licensee and co-owner Kristine Carrillo has submitted the reports to LPA during a previous visit on 8/23/2021.

See 809-D for Type B deficiency cited during today's visit.

Exit interview conducted with Monica Barcena.
Notice of Site visit was posted at the time of inspection, and must remain posted for 30 days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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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Document Has Been Signed on 11/05/2021 12:49 PM - It Cannot Be Edited


Created By: Diana Campos On 11/05/2021 at 11:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: KIDS FIRST ACADEMY
FACILITY NUMBER: 073407406

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2021
Section Cited
CCR
101212(a)(d)(1)(B)

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Reporting Requirements
(a) Each licensee or applicant shall furnish to the Department reports as required by the Department including, but not limited to, the following...
This requirement was not met as evidenced by:
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This deficiency was corrected during visit when staff submitted the missing Unusual Incident Reports
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During a complaint investigation Staff (co-owner) admitted to forgetting to call licensing office to report unusual incident. This poses a potential risk to the 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:Sherelle Johnson
LICENSING EVALUATOR NAME:Diana Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: KIDS FIRST ACADEMY
FACILITY NUMBER: 073407406
VISIT DATE: 11/05/2021
NARRATIVE
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101212 Reporting Requirements ......CONT'D-------------------------------
(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, 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 containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
(1) Events reported shall include the following:
(B) Any injury to any child that requires medical treatment.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
LIC809 (FAS) - (06/04)
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