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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408230
Report Date: 05/31/2024
Date Signed: 05/31/2024 03:03:52 PM

Document Has Been Signed on 05/31/2024 03:03 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:SRVUSD EARLY CHILDHOOD EDUCATION PP - WALT DISNEYFACILITY NUMBER:
073408230
ADMINISTRATOR/
DIRECTOR:		KATHLEEN WITTFACILITY TYPE:
850
ADDRESS:3250 PINE VALLEY ROADTELEPHONE:
(925) 552-2980
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 9DATE:
05/31/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Joan SandovalTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On May 31, 2024 at 11:45am, Licensing Program Analyst (LPA) Julia Placencia arrived unannounced for an Annual/Random Inspection. LPA met with site supervisor Joan Sandoval. Present during inspection were nine children and two staff members (Lisa Koby and Tori Javier). This is a Title V school that operates on the Walt Disney Elementary School campus in room K1. The facility was toured for a health and safety inspection. Hours of operation are Monday, Tuesday, Thursday, Friday, 11:40am to 3:00pm, and Wednesday 12:00pm to 3pm. The facility is closed during the summer months.

Disinfectants, cleaning solutions, poisons and other items that are dangerous to children were inaccessible during the visit. The toilets and sinks were safe, sanitary and in operable condition. Furniture and equipment are in good condition, and floors are free of tripping hazards. Drinking water is available both indoors and outdoors. Children either bring lunch or it is provided by the elementary school. Snacks are also provided by the elementary school and menus are posted. There are no pools or similar bodies of water at this facility. Outdoor activity space and playground equipment observed to be safe and free of hazards. Climbing equipment is properly anchored to the ground with adequate and appropriate cushioning material to absorb falls. There is a shaded area provided for the children. Fire/Disaster Drills are conducted every 2-3 months as scheduled for the entire elementary school, however, they have not been documented. Required licensing documents were posted by the front door. Facility has a fully charged fire extinguisher. Carbon monoxide and smoke detector was observed and maintained by the school district.



The facility is operating within its licensed capacity. The teacher/child ratio was met, and LPA did not observe any child left without supervision. A physical census was taken of all children present and crossed referenced with the sign in/out log. Children and staff records were reviewed. Staff have required qualifications and mandated reporter training.

***Continued on LIC 809C...
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SRVUSD EARLY CHILDHOOD EDUCATION PP - WALT DISNEY
FACILITY NUMBER: 073408230
VISIT DATE: 05/31/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test.



LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP

LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.


***Continued on LIC 809C...
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
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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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: SRVUSD EARLY CHILDHOOD EDUCATION PP - WALT DISNEY
FACILITY NUMBER: 073408230
VISIT DATE: 05/31/2024
NARRATIVE
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Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

The following deficiencies were observed during today’s inspection:
  • S1 does not have a Health Screening (LIC 503) on file.
  • S1 does not have proof of measles immunity on file.
  • Children's files do not have ID and Emergency form on file (LIC 700).
  • S5 does not have Consent (LIC 627), Parents Rights (LIC 995) and Personal Rights (LIC 613A) forms on file.

See LIC809D for deficiencies cited during today's inspection. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
***Please see LIC 9102 for Advisory Notes.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the facility representative Joan Sandoval.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/31/2024 03:03 PM - It Cannot Be Edited


Created By: Julia Placencia On 05/31/2024 at 02:24 PM
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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRVUSD EARLY CHILDHOOD EDUCATION PP - WALT DISNEY
FACILITY NUMBER: 073408230

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as S1 did not have proof of measles immunity on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2024
Plan of Correction
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Licensee shall submit proof of S1's measles immunity to LPA by due date of 6/10/24.

***Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as S1 does not have proof of health screening on file (LIC 503). This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2024
Plan of Correction
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Licensee shall submit proof of S1's health screening (LIC 503) to LPA by due date of 6/10/24.

***Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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:Jason Jang
LICENSING EVALUATOR NAME:Julia Placencia
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


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Document Has Been Signed on 05/31/2024 03:03 PM - It Cannot Be Edited


Created By: Julia Placencia On 05/31/2024 at 02:24 PM
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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: SRVUSD EARLY CHILDHOOD EDUCATION PP - WALT DISNEY
FACILITY NUMBER: 073408230

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(a)
Child's Records
(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as Identification and Emergency forms (LIC 700) were not observed in children's files. Additionally S5 is missing Consent (LIC 627), Personal Rights (LIC 613A) and Parents Rights (LIC 995) forms. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2024
Plan of Correction
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As the school year is coming to an end, Licensee is advised to submit a statement ensuring all required licensing forms will be completed and filed in each child's file for the upcoming 24/25 school year.
***Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jason Jang
LICENSING EVALUATOR NAME:Julia Placencia
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


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