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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416394
Report Date: 04/28/2022
Date Signed: 04/28/2022 05:11:17 PM

Document Has Been Signed on 04/28/2022 05:11 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:LOS ARROYOS CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434416394
ADMINISTRATOR:OKSANA OKSFACILITY TYPE:
830
ADDRESS:885 MORO DRIVETELEPHONE:
(408) 763-7827
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY: 12TOTAL ENROLLED CHILDREN: 12CENSUS: 10DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Oksana OksTIME COMPLETED:
03:01 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 1 Year inspection. LPA met with Director Oksana Oks and explained the reason for the inspection. Present during today's inspection were 10 infants and at least 4 staff. The facility was within ratio during today's inspection.

There is a board to post required postings, such as license and notification of parents. There is a working phone at the center. The hours of operation are Monday through Friday 7AM to 6PM. Facility uses an electronic sign in/sign out. LPA reviewed electric sign in/sign out.

LPA toured the inside and outside of the facility. All disinfectant, cleaning supplies, and other items that are dangerous to children were observed to inaccessible. LPA observed that there were two packs of Swiffer wet wipes and a pack of Lysol disinfectant spray underneath the sink. Director moved the packs of Swiffer and Lysol to a lock cabinet. LPA also observed that there were perfume and ointment for the staff in the drawer next to the changing table, which the latch was not working. Staff stated that they will remove items. LPA observed that there is age-appropriate toys and equipment for children. There is a changing table, which is within arms reach of a sink. Changing table meets the requirement. LPA observed there were soiled diapers in a trash can, which did not have a tight-fitted lid. Director place lid pack on the trash during inspection. Director understands that trash can for waste needs to be in good repair and tight-fitted. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire drill was conducted on 03/24/2022. Director stated that there are no weapons, such as firearms, stored in the facility.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: LOS ARROYOS CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434416394
VISIT DATE: 04/28/2022
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The outdoor area is fenced. There are age appropriate toys and equipment for children. Shaded rest area is provided through trees, building over-hang, and canopy. LPA observed
that part of the yard is fenced off. Director stated that they are currently using it as storage. Director stated that they would like to make it permanent and will send an updated LIC 999: facility sketch to Licensing. Director understands that Licensing would need to remeasure the outdoor space to ensure that there is enough square footage.

LPA discussed the safe sleep regulations with Director Oksana Oks and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA reviewed LIC 9227: Individual Sleeping Plan and documentation of every 15 minutes. LPA discussed with Director that the documentation needs to include the time that the child was checked. The chart only has the time that the child went to sleep and 15 minute check. Director stated that she will updated chart, so staff can include the time checked. LPA also informed Director Oksana Oks of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Facility currently does not have any children who requires Incidental Medical Services (IMS). For IMS information, see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm


-----------------------------continues on 809 dated 04/28/2022 page 3----------------------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: LOS ARROYOS CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434416394
VISIT DATE: 04/28/2022
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Meals and snacks are prepared through third party. There is kitchen to store and finish heating food. Kitchen was observed to be clean. Menu was observed to be posted. Facility has a waiver to prepare bottles with formula. Drinking water is provided through individual sippy cups. There is a sink to prepare bottles and food.

A copy of the facility roster was obtained. 11 children's files were reviewed during today's inspection. The records reviewed include but not limited to Needs and Service Plan and LIC 9227: Individual Infant Sleeping Plan. LPA observed that authorized representatives did not sign Section D of the LIC 9227. LPA reminded Director to ensure that the form is filled out completely, such as the date that parent observed child roll over and that page 2 of the LIC 9227 is filled out. LPA also observed that C-1 had a physician's letter on file, but it did not include screening for TB risk assessment. Director stated that they will provide the form to C-1's parent to have their physician fill it out. Director stated that she will send proof to Licensing; along with C-2's physician's report. C-2 enrolled on 04/23/2022.

5 staff files were reviewed during today's inspection. The records reviewed include but not limited to education credit, Mandated Reporter training, and immunization records. S-1 and S-2 have not renewed Mandated Reporter training within 2 years. S-1 completed it on 02/18/2020 and S-2 completed it on 02/18/2020. Director stated that she will send proof to Licensing once staff obtain certificate.

All staff have cleared fingerprints. Director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: LOS ARROYOS CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434416394
VISIT DATE: 04/28/2022
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As a result of this inspection, two type B citations and two technical violation were issued. Exit interview conducted and report was reviewed with Director Oksana Oks.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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Document Has Been Signed on 04/28/2022 05:11 PM - It Cannot Be Edited


Created By: Samantha Yip On 04/28/2022 at 01:45 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: LOS ARROYOS CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434416394

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101239(f)(1)
Fixtures, Furniture, Equipment and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers used for storage of solid wastes, including moveable bins, shall have a tightfitting cover that is kept on; shall be in good repair; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Trash can for diapers did not have a tight-fitted lid, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2022
Plan of Correction
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Deficiency was corrected during today's inspection. Director placed lid back on trash can and is functioning.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 in 2 out 4 staff, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/14/2022
Plan of Correction
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By POC 07/14/2022, staff will complete mandated reported training and send proof of completion to Licensing.
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:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


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