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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274413132
Report Date: 10/28/2022
Date Signed: 11/01/2022 01:05:28 PM

Document Has Been Signed on 11/01/2022 01:05 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:NORTHMINSTER PRESBYTERIAN INFANT CAREFACILITY NUMBER:
274413132
ADMINISTRATOR:ANDY RAUSCHFACILITY TYPE:
830
ADDRESS:315 EAST ALVIN AVENUETELEPHONE:
(831) 449-2717
CITY:SALINASSTATE: CAZIP CODE:
93906
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 3DATE:
10/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Teresa RicoTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Larios, conducted an unannounced case management visit today. LPA met with staff Teresa Rico and discussed the nature of today's visit.

LPA conducted a complaint investigation on May 11, 2022 and became aware of a day care child (C-1) incident that occurred on February 2022 where staff (S-1) used foot to avoid child (C-1) from getting up. LPA conducted staff interviews.

A deficiency was issued during today's visit. LPA conducted an exit interview with staff Teresa Rico where this report was reviewed and copy of appeal rights was provided. Please refer to page 809-D for citation, description, and plan of correction.

A Notice of Site Visit has been issued and must remain posted for 30 consecutive days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2022
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
Document Has Been Signed on 11/01/2022 01:05 PM - It Cannot Be Edited


Created By: Elizabeth Larios On 10/28/2022 at 04:22 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: NORTHMINSTER PRESBYTERIAN INFANT CARE
FACILITY NUMBER: 274413132

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2022
Section Cited
CCR
101223(a)(1)

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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:

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Licensee agreed to conduct training with staff regarding Personal Rights. Licensee will submit poof of training to CCL by the POC due date, 11/04/2022.
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LPA conducted a complaint investigation on May 11, 2022 and staff interviews and became aware of a day care child (C-1) incident that occurred on February 2022 where staff (S-1) used foot to avoid child ( C-1) from getting up. LPA did not have evidence to proof that child was punished or abuse.

This poses a potential risk to the 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:Joel Segura
LICENSING EVALUATOR NAME:Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2022


LIC809 (FAS) - (06/04)
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