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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009973
Report Date: 11/23/2021
Date Signed: 11/23/2021 05:16:15 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:VCUSD GLEN COVE CDC P/SFACILITY NUMBER:
483009973
ADMINISTRATOR:CLAUDETTE, KELLYFACILITY TYPE:
850
ADDRESS:501 GLEN COVE PARKWAYTELEPHONE:
(707) 556-8491
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:48CENSUS: 2DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Claudette KellyTIME COMPLETED:
05:30 PM
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A Required inspection was made to the facility by Licensing Program Analysts (LPAs), M. Augustin and E. Hernandez Torres. The facility file was reviewed prior to this visit. The Director stated the school district ensured that district staff obtained criminal record or exemptions prior to working at the facility. This program operates in DK and A-5 classrooms on the premise of the Glen Cove Elementary School, is operated by a public agency and is a Title 5 funded program. The facility did not have a waiver.

The facility’s operating hours are 7:00am to 5:00pm, Mon-Fri. The facility was toured inside and outside and the floor and yard plan submitted by the licensee were verified. The items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children. LPAs did not observe any poison(s). The facility was free of flies, insects and rodents. The toys, floors, desks and other equipment and surfaces are clean, toxic free, safe and in good condition. There is uncontaminated drinking water available to children both indoors and outdoors. There were water fountains in each classrooms and children are provided with disposable cups to obtain water. The Center Director stated children may also bring their own water bottles. The DK and A-5 classrooms had hardwired smoke detectors and functional working carbon monoxide detectors, and a fully charged 2A10BC fire extinguisher. The children's bathrooms are in safe and sanitary condition. A current menu and activities schedule were posted. The contact information for the local public health department and parents' rights in A-5 class were not posted. The school district food services provide breakfast, lunch and snacks to the facility. Food is properly stored and refrigerated as needed. Garbage cans containing solid waste have tight fitting lids. The playground was free of hazards and there was wood chips underneath and around the areas of the high climbing equipment(s). The playground equipment and surface areas are in safe condition. There were no bodies of water observed. The Director stated no firearms or other dangerous weapons were stored on site and none were observed. During today's inspection, staffing ratios were being met and two children were being supervised by one teacher and four Child Development Associate (CDA). The facility was operating within the licensed capacity. (Continue to LIC 809-C)
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: VCUSD GLEN COVE CDC P/S
FACILITY NUMBER: 483009973
VISIT DATE: 11/23/2021
NARRATIVE
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The classrooms had cubbies for the children to store their belongings. The facility roster of the children in care was reviewed and was complete. The children's sign in/out procedure were reviewed and complete. Staff (CD & S1-S6) records were reviewed at 12:40pm and staff records reviewed revealed CD and S1 were missing health screening forms. Children's record were reviewed at 1:50pm and identification and emergency information, immunization, as well as transcribed CDPH 286 were on file.

The facility representative 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 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 (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.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the facility representative, Kelly Claudette. The following deficiency was cited during today's inspection. See LIC 809-D. Appeal Rights were provided.

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.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: VCUSD GLEN COVE CDC P/S
FACILITY NUMBER: 483009973
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(2)
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records reviewed at 12:40pm, the licensee did not comply with the section cited above. Staff records reviewed revealed that CD and S1 were missing completed health screening forms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2021
Plan of Correction
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The Center Director stated she would submit completed LIC 503 for CD and S1 to the Department by 12/07/21 via mail, email or fax.

Email: Melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2021
LIC809 (FAS) - (06/04)
Page: 6 of 6