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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 440710237
Report Date: 09/19/2023
Date Signed: 09/19/2023 02:02:21 PM

Document Has Been Signed on 09/19/2023 02:02 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:DE LA VEAGA CKC INC.FACILITY NUMBER:
440710237
ADMINISTRATOR:MILLETE, JAHMARFACILITY TYPE:
840
ADDRESS:1145 MORRISSEY BOULEVARDTELEPHONE:
(831) 461-5229
CITY:SANTA CRUZSTATE: CAZIP CODE:
95065
CAPACITY: 200TOTAL ENROLLED CHILDREN: 120CENSUS: 0DATE:
09/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Jahmar Millete, Blaise Skelton, Kylie RobertsTIME COMPLETED:
02:18 PM
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Licensing Program Analyst (LPA), Cortney Nelson, met with Site Director, Jahmar Millete, to follow-up on incident that occurred 8/24/2023 regarding a child that was left outside without supervision. Upon arrival, LPA was admitted into the facility by Jahmar and conducted interview with him. LPA additionally met with After-School Coordinator, Blaise Skelton, and Executive Director, Kylie Roberts, who arrived approximately 30 minutes after LPA's arrival.

An unusual incident report was received by the San Jose Regional office on 9/5/2023, to self-report that on 8/24/2023, a child was left unattended at the playground and was not realized until parent/guardian came to pick up the child. The child was left unattended for less than five minutes, when it was realized that the child did not return to the classroom with outside staff and was still playing on the play structure. There were other children, not affiliated with CKC, out on the play structure at the same time the child was left outside.

Jahmar states that follow-up has been conducted with staff regarding importance of visual supervision of children at all times and headcount protocols during transitions. Staff will now have accessible digital rosters via facility cell phone and tablets to confirm which children are signed in/out for maintaining count of children present.

LPA Nelson reminded Jahmar, Kylie, and Blaise of reporting requirements to Licensing and advised that initial reporting shall be received within 24 hours of the incidents occurrence and written report (LIC624) shall be submitted within seven (7) days. The Department was not notified of the incident until written report was received on 9/5/2023.

LPA informed Executive Director, Kylie Roberts, that this report dated (9/19/2023) documents one Type A citation, which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2023
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 09/19/2023 02:02 PM - It Cannot Be Edited


Created By: Cortney Nelson On 09/19/2023 at 01:10 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: DE LA VEAGA CKC INC.
FACILITY NUMBER: 440710237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2023
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation.

This requirement was not met as evidenced by:
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The Site Director has conducted additional training with staff regarding the importance of visual supervision at all times. Staff will now have access to a digital roster to confirm which children are signed in.
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The Licensee did not ensure that children were visually supervised at all times as a child was left unattended on the playstructure, while other children (unaffiliated with CKC) were on the playstructure, which poses an immediate risk to the health, safety, and personal rights of children in care.
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Follow up POC has already been conducted by the facility and will continue to be followed up on with staff moving forward.
-Zero tolerance citation, civil penalty assessed-

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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:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023


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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DE LA VEAGA CKC INC.
FACILITY NUMBER: 440710237
VISIT DATE: 09/19/2023
NARRATIVE
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Also, LPA informed the Executive Director to provide a copy of this licensing report dated (9/19/2023) that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

As a result of today's inspection, deficiencies have been cited, see LIC809-D.

Exit interview conducted and report was reviewed with Executive Director, Kylie Roberts, and After-School Coordinator, Blaise Skelton.

A NOTICE OF SITE VISIT HAS BEEN GIVEN AND MUST BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/19/2023 02:02 PM - It Cannot Be Edited


Created By: Cortney Nelson On 09/19/2023 at 01:36 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: DE LA VEAGA CKC INC.
FACILITY NUMBER: 440710237

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/22/2023
Section Cited
CCR
101212(d)

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101212 Reporting Requirements (d) Upon the occurrence... 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... shall be submitted... within seven days following the occurrence...

This requirement was not met as evidenced by:
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The facility to submit plan of correction (POC) detailing who will be responsible for reporting within 24 hours of incident occurrences to the Department and submitting unusual incident reports. POC to be submitted to the Department by 9/22/2023.
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The Licensee did not notify the Department of the unusual incident until written report was received 9/5/2023, twelve days after the incident occurred, which poses a potential threat to the health, safety, and personal rights 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:Joel Segura
LICENSING EVALUATOR NAME:Cortney Nelson
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023


LIC809 (FAS) - (06/04)
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