274408890-12-8-2021-07-CC-SCES-C9HUCJ-20211208142803

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 274408890
Report Date: 12/08/2021
Date Signed: 12/08/2021 02:28:27 PM

Document Has Been Signed on 12/08/2021 02:28 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	KING CITY EARLY EDUCATION CENTER		FACILITY NUMBER:	274408890
ADMINISTRATOR:	SUSANA TRUJILLO		FACILITY TYPE:	850
ADDRESS:	520 COLLINS STREET		TELEPHONE:	(831) 385-2222
CITY:	KING CITY	STATE: CA	ZIP CODE:	93930
CAPACITY: 48	TOTAL ENROLLED CHILDREN: 48	CENSUS: 32	DATE:	12/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Susana Trujillo		TIME COMPLETED:	02:35 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/08/2021 Licensing Program Analyst (LPA), Susy Cervantes, conducted an annual visit to the Facility today. LPA met with Susana Trujillo, director, and explained the nature of today’s visit. LPA toured the Facility both inside and outside during today’s visit. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents’ Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus and Activity Schedule. All staff are employed by the King City Union School District and are finger printed and cleared by their employer. LPA observed 3 teacher with 16 children in Room 1 and 3 teachers with 16 children in Room 2 during today’s visit. LPA observed that the teacher/child ratio was in compliance during today’s visit. Director understands the conditions, limitations, and capacity specifications of the Facility license. Director understands that children shall be visually supervised at all times. LPA observed that all floors are clean and safe for all children and staff. All materials and surfaces accessible to children are toxic free. Furniture and equipment are in good condition, free of sharp, loose, or pointed parts. Drinking water is readily available for the children in each room and in the outdoor playground area via drinking fountains and water bottles. LPA observed solid waste containers with tight-fitting lids in each room and in the playground area. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Director states that there are no weapons on the premises. *Continues on report dated 12/08/2021 pg. 1/2*

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

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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Document Has Been Signed on 12/08/2021 02:28 PM - It Cannot Be Edited

Created By: Susy Cervantes On 12/08/2021 at 02:14 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KING CITY EARLY EDUCATION CENTER	FACILITY NUMBER: 274408890
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101217(d)

Personnel Records

(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which staff files were not availbale for review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2022
	Plan of Correction
1 2 3 4	Director will submit all staff files to the San Jose Regional office (SJRO) by close of business (COB) on January 05, 2021.

Type B

Section Cited

CCR

101223(b)(1)

Personal Rights

(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which CH 07 is missing a signature on LIC 613A which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/10/2021
	Plan of Correction
1 2 3 4	Director will provide form LIC 613A to parents to be signed. Director will submit proof of completion to SJRO by COB on December 10, 2021.

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:

Mary Segura

LICENSING EVALUATOR NAME:

Susy Cervantes

LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: KING CITY EARLY EDUCATION CENTER	FACILITY NUMBER: 274408890
	VISIT DATE: 12/08/2021

NARRATIVE

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Continuation of report dated 12/08/2021 pg. 2/2

Snacks are provided by the King City Union School District. Food prep area has refrigerators, hot and cold running water, and a microwave. Cleaning supplies, poisons, and other dangerous items are inaccessible to the children and stored in the hallway closet. Storage area for poisons is locked. Any medications at the Facility are stored appropriately and in an off-limits area of the Facility, office. LPA observed functioning carbon monoxide detectors.

The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. There is also sufficient resilient materials, tan bark, in the outdoor playground area. LPA observed no bodies of water.

LPA observed 10 children files, CH 07 LIC 613A has not been signed. LPA was unable to review staff files. Director understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips), director has current CPR and First aid that expires on 04/2023. LPA reviewed the sign in/out record and observed the authorized representative who signs the child in/out uses their full legal signature and records the time of the day.

Incidental Medical Services (IMS) policy was discussed with the licensee. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The licensee is not providing IMS at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Type B deficiencies were cited during today's visit. Director was informed that failure to correct the deficiencies by the specified Plan of Correction Due Date will result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

Exit interview conducted and report was reviewed with the director, Susana Trujillo. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

LIC809 (FAS) - (06/04)

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