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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444415204
Report Date: 11/05/2021
Date Signed: 11/05/2021 02:00:43 PM

Document Has Been Signed on 11/05/2021 02:00 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:LIFE SPRING COMMUNITY PRESCHOOL AND INFANT CAREFACILITY NUMBER:
444415204
ADMINISTRATOR:DESTINY MALONEFACILITY TYPE:
830
ADDRESS:2560 SOQUEL AVENUETELEPHONE:
(831) 477-0584
CITY:SANTA CRUZSTATE: CAZIP CODE:
95062
CAPACITY: 19TOTAL ENROLLED CHILDREN: 16CENSUS: 9DATE:
11/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Destiny MaloneTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Goodell met with director Destiny Malone for a case management regarding a self reported incident that was reported to that occurred on 10/18/21 and reported to the department on 10/19/21. During inspection LPA observed four children in the Starfish 2 infant classroom with two staff and five children in the Starfish 1 infant classroom with three staff. All individuals subject to criminal background review have obtained a criminal record clearance.

During inspection LPA toured all areas accessible, obtained documents and photos related to the incident. LPA also conducted staff interviews. During inspection LPA learned and observed the portable heater in Starfish classroom 2 not being used and the wall heater not being used. LPA also observed the portable heater in Starfish 1 classroom stored inaccessible to children. However, although staff were present and tended to child #1 an incident occurred on 10/18/21 when a portable heater was stored accessible to children which resulted in child #1 touching the screen of the portable heater and obtained minor hand blisters which poses a risk to children in care. LPA discussed heaters shall be made inaccessible to children to ensure children's safety and all children shall be protected against hazards within the center through provision. Director acknowledged requirement and stated shelving will be installed to store hazardous items out of reach of children.

Title 22 deficiency cited on 809-C. Report was reviewed and discussed. Appeal rights also issued and discussed. Notice of Site Visit was issued and must be posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kristal Goodell
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
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 11/05/2021 02:00 PM - It Cannot Be Edited


Created By: Kristal Goodell On 11/05/2021 at 01:38 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: LIFE SPRING COMMUNITY PRESCHOOL AND INFANT CARE
FACILITY NUMBER: 444415204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2021
Section Cited
CCR
101239(c)

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Fixtures, Furniture, Equipment and Supplies. Fireplaces and open-faced heaters shall be made inaccessible to children to ensure children's safety. This requirement is not met due to an incident occurred on 10/18/21 when a portable heater was stored accessible to children which resulted in child #1 touching
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LPA discussed heaters shall be made inaccessible to children to ensure children's safety and all children shall be protected against hazards within the center through provisions. Director acknowledged requirement and stated shelving will be installed to store hazardous items out of reach of children and a higher screen will be replaced on the wall heater.
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the screen of the portable heater and obtained minor hand blisters which poses a risk to children in care.
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Proof will be submitted to LPA by POC due date 11/17/21.

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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:Diana Stephenson
LICENSING EVALUATOR NAME:Kristal Goodell
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2021


LIC809 (FAS) - (06/04)
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