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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444414395
Report Date: 12/06/2022
Date Signed: 12/06/2022 02:20:51 PM

Document Has Been Signed on 12/06/2022 02:20 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:GIVING TREE ACADEMYFACILITY NUMBER:
444414395
ADMINISTRATOR:ELIZABETH ASADIFACILITY TYPE:
830
ADDRESS:175 LAWRENCE AVENUE, BLDG.BTELEPHONE:
(831) 722-7811
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 24TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Marcela MartinezTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA), Cortney Nelson, met with Giving Tree Academy representative, Marcela Martinez, and explained purpose of today's visit- to conduct annual Required- 1 Year inspection. Upon arrival, Marcela let LPA know that Site Director, Jenifer Sosa, is on vacation and is expected to return on Monday, 12/12/2022. Marcela is acting in Jenifer's role while she is away. LPA observed that there were four (4) infants present today with two (2) staff members (Margarita & Angela). The facility is located at Trinity Lutheran Church in Building B and the hours of operation are Monday-Friday 7:00AM-5:00PM. LPA observed all required postings near the entrance of the facility.

LPA reviewed sign-in/out sheets and observed they are completed with full legal signature and time of day. There are three (3) 3A40BC fire extinguishers (last serviced 10/2018) and LPA advised that fire extinguishers are serviced at least annually. The facility has a built in fire detection system and did not have a carbon monoxide detector. There are no children in care who require Incidental Medical Services and there is one (1) child who currently has medication. LPA observed that the medication is properly stored out of reach of children with the proper documentation. LPA advised that medication should remain in the original packaging with physicians label. The Facility Representative states that there are no weapons or firearms on the premises.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Child Care Centers, Section 101173 and 101226. 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 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
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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: GIVING TREE ACADEMY
FACILITY NUMBER: 444414395
VISIT DATE: 12/06/2022
NARRATIVE
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Indoor areas of the facility were inspected by the LPA today and observed to be clean, orderly, and safe for the day care infants. Building B has three (3) classrooms and LPA observed infants eating in Classroom A, playing with manipulative toys and singing in Classroom C, and napping in Classroom B. Furniture, such as tables, chairs, and shelves, are in good condition and safe for infants. The floors were clean and free of tripping hazards. Drinking water is readily available via water dispensers and water bottles from home labeled with the infant’s names. Staff and infant’s bathrooms are clean, sanitary, and operable. There is a properly equipped diaper changing table located in the bathroom that is within arms reach of a sink. There is a separate staff bathroom, not utilized by the infants, which an isolated child can use if necessary. There is a working telephone in the facility. All food is provided by the parents and LPA observed proper labeling with the infants name and date.

LPA discussed the safe sleep regulations with the Facility Representative 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.

The outdoor area of the facility was inspected and observed to be fenced in. LPA observed sufficient resilient materials (tanbark) to absorb falls. There is a sandbox located outside that is properly maintained and safe for children's use. LPA advised that the outdoor space needs general cleaning as the plastic toys have noticeable dirt, wooden platform for playing is collapsing under the tarp, and some plastic toys appear unstable for children's use. No outdoor bodies of water were observed during today’s inspection and shaded rest area is provided for infants by canopy.

Four (4) infant's files were reviewed during today’s inspection and most required documents were present. Two (2) staff files were reviewed and all required documents were present. There is at least one staff member present with current CPR/First-Aid that expires 1/2023 and current Mandated Reporter Training that expires on 7/18/2024. LPA reminded the Facility Representative that the Mandated Reporter Training must be renewed by all staff every 2 years.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
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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: GIVING TREE ACADEMY
FACILITY NUMBER: 444414395
VISIT DATE: 12/06/2022
NARRATIVE
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The Facility representative understands that the Site Director shall be on the premises during the hours the center is in operation and that children at the center shall be visually supervised at all times. LPA reminded the Facility Representative 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, such as field trips.

Exit interview conducted and report was reviewed with the Giving Tree Academy representative, Marcela Martinez.

As a result of today’s inspection, deficiencies were cited, see 809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

LPA reminded the Facility Representative of the required water lead testing for Child Care Centers that is due by 1/1/2023. All centers are required to have any faucets used for drinking and food preparation to be tested for lead by a certified water sampler. LPA advised reviewing PIN 22-20-CCP for additional guidance.

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.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Cortney Nelson
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
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Document Has Been Signed on 12/06/2022 02:20 PM - It Cannot Be Edited


Created By: Cortney Nelson On 12/06/2022 at 12:40 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: GIVING TREE ACADEMY
FACILITY NUMBER: 444414395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.954
Licensure Requirements
Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as Building B, with three (3) infant classrooms, did not have a carbon monoxide detector, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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The Site Director will purchase a carbon monoxide detector and install into the facility by 12/16/2022. A photo will be submitted to the Department of the carbon monoxide properly installed.
Type B
Section Cited
CCR
101226(e)(1)(B)
Health-Related Services
(1) All prescription and nonprescription medications shall be centrally stored in accordance with the requirements specified below: (B) Each container shall have an unaltered label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above for one (1) infant in care who has prescription body cream without original packaging, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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The Site Director will obtain the original packaging from parents of infant and ensure that packaging follows the parents/physicians dosage, has the child's name, and note the date of exipration. Original packaging photo to be submitted by 12/16/2022 and all medication moving forward should be properly labeled.
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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


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Document Has Been Signed on 12/06/2022 02:20 PM - It Cannot Be Edited


Created By: Cortney Nelson On 12/06/2022 at 12:40 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: GIVING TREE ACADEMY
FACILITY NUMBER: 444414395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(d)(2)
Disaster and Mass Casualty Plan
(d) Disaster drills shall be conducted at least every six months. (2) The drills shall be documented. This documentation shall be kept in the child care center for at least one year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as no staff were able to provide documented fire/emergency drill log, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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The Site Director will conduct a fire/emergency disaster drill no later than 12/16/2022 and submit proof of completion to the Department. All future drills must be maintained and logged for each component, including date and number of children present.
Type B
Section Cited
CCR
101238(a)
Buildings and Grounds
(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the outdoor play space for infants is equipped with plastic equipment that needs cleaning, wooden floor needs removal/ repair, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2023
Plan of Correction
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The Site Director will address the outdoor play yard for infants and clean any large plastic toys that are to be kept as there is visible dirt built up on them. The wooden stage, covered in tarp, is structurally unsafe and should be repaired or removed. Pictures of cleaned outdoor space will be submitted to the Department by 1/6/2023.
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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


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Document Has Been Signed on 12/06/2022 02:20 PM - It Cannot Be Edited


Created By: Cortney Nelson On 12/06/2022 at 12:40 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: GIVING TREE ACADEMY
FACILITY NUMBER: 444414395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(6)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 101219.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obervation, interview, and record review, the licensee did not comply with the section cited above for three (3) out of four (4) infant files reviewed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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The Site Director will submit signed admission agreements for the children missing in their files. The Site Director will additionally update the agreement to reflect current services provided and make any changes necessary (101219 Admission Agreements from CA Code of Regulations)
Type B
Section Cited
CCR
101419.3(a)
Modifications to Infant Needs and Services Plan
(a) The written infant needs and services plan shall be updated at least quarterly, or as often as necessary to assure its accuracy.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as three (3) out of four (4) infants present have not updated their Needs and Services plan at least quartly, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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For any infants that will still be under 24 months, an updated Needs and Services Plan will be submitted for those missing. The Site Director will submit written declaration of how these will be maintained in the future at least quarterly.
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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


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Document Has Been Signed on 12/06/2022 02:20 PM - It Cannot Be Edited


Created By: Cortney Nelson On 12/06/2022 at 12:40 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: GIVING TREE ACADEMY
FACILITY NUMBER: 444414395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101227(a)(20)
Food Services
(20) All equipment (fixed or mobile), dishes and utensils shall be kept clean and maintained in safe condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as food for the infants was observed to be warmed up using a crock-pot, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/06/2023
Plan of Correction
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The Site Director will purchase a microwave for the proper heating of children's food, as using the crock-pot with plastic containers is a potential hazard. A microwave or other alternative will be submitted to the Department by 1/6/2023.
Type B
Section Cited
CCR
101239.1(b)(5)
101239.1 Napping Equipment (b) Floor mats used for napping shall be: (5) Maintained in a safe condition with no exposed foam.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above for nap mats provided to the infants were observed to have exposed foam, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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The Site Director will remove all nap mats that have exposed foam and replace to ensure that enough children/infants have access to the nap mats during nap time. Picture of new foam mats or invoice to order new mats should be submitted to the Department by 12/16/2022.
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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


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Document Has Been Signed on 12/06/2022 02:20 PM - It Cannot Be Edited


Created By: Cortney Nelson On 12/06/2022 at 01:01 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: GIVING TREE ACADEMY
FACILITY NUMBER: 444414395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.841
1596.841 Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as the infant roster only has the names of the children enrolled and staff were unaware of another roster, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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The Site Director will submit children's roster that include all components as listed in the Health and Safety code above. A roster of all infants enrolled should be submitted to the Department by 12/16/2022. (LIC9040 can be used and should be maintained for Three years.)
Type B
Section Cited
CCR
101161(a)
101161 Limitations on Capacity (a) A licensee shall not operate a child care center beyond the conditions and limitations specificed on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above for one (1) out of four (4) infants present today, as one infant is over 24 months old, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2022
Plan of Correction
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The Site Director will immediately transition the preschool-age child out of the infant component and ensure an exception request is submitted in the future for any children that may need time adjusting out of the infant program. Two additional infants are turning 24 months in December and the Site Director will submit plan of action for the infants current enrolled by 12/16/2022.
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: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022


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