444415700-6-17-2021-07-CC-KGOL-C43W4D-20210617165722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444415700
Report Date: 06/17/2021
Date Signed: 06/17/2021 04:57:38 PM

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:	BUILDING KIDZ SCOTTS VALLEY		FACILITY NUMBER:	444415700
ADMINISTRATOR:	MISTRY, ANISHA		FACILITY TYPE:	850
ADDRESS:	106 VINE HILL SCHOOL ROAD		TELEPHONE:	(831) 438-4813
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	45	CENSUS: 33	DATE:	06/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Marissa Cooney-Moore		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Goodell met with staff member Marissa Cooney-Moore for an unannounced Annual Inspection. The facility’s hours of operation are Monday-Friday, 7:00AM-6:00pm. LPA conducted a census of 6 children present with 1 staff in toddler classroom, 16 children present with two staff in the preschool classrooms and 11 children present with 2 staff in the pre-k classroom. All individuals present have obtained fingerprint clearance through Community Care Licensing. LPA observed required postings: Facility License (LIC 203A), Personal Rights (LIC9040), Emergency Disaster Plan (LIC610), Earthquake Preparedness Checklist (LIC9148), and Parent’s Rights Poster (PUB393). LPA toured all activity/classroom areas, children’s furniture, play equipment, napping equipment, food service area, and restrooms. LPA learned the children's restroom in the kinder classroom and sink in toddler classroom are out of service which poses a potential risk to children in care. Proof of repair requests will be submitted to LPA via email by 7/2/2021. Due to COVID guidelines LPA observed parent sign/out station located at the entrance of the facility and the electronic sign/in-sign/out indoors. Facility provides morning/afternoon snack and lunches are provided by parents. LPA observed current menu and activity posted. LPA observed outdoor area and play equipment. LPA observed ground visible in areas of the climbing structure where cushioning is required to observe a fall which poses a potential risk to children in care. Proof of additional cushion will be submitted to LPA via email by 7/2/2021. LPA observed stored inaccessible to children. LPA observed an Epi-Pen unlabeled which poses an immediate risk to children in care. LPA observed water is accessible to children both indoor and outdoor. LPA observed fire extinguisher 3A40BC, smoke and carbon monoxide detectors. LPA observe fire drill log and children roster maintained. Report continues on LIC 809-C

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kristal Goodell	TELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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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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: BUILDING KIDZ SCOTTS VALLEY	FACILITY NUMBER: 444415700
	VISIT DATE: 06/17/2021

NARRATIVE

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LPA reviewed children files. Documents included Identification and Emergency Information (LIC700), Child’s Preadmission Health History (LIC702), Child’s Preadmission Health Evaluation (LIC701), Consent for Medical Treatment (LIC627), Notification of Parent’s Rights (LIC 995), Personal Rights (LIC613A).

LPA reviewed staff files and educational requirements. Documents included Health Screening Report (LIC503), TB Clearance, Personal Record (LIC501), Criminal Record Statement (LIC508), Notice of Employee Rights, Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC9108) and certificate for Mandated Reporter Training. LPA observed that at least one staff member present during today’s inspection has current Pediatric CPR/First Aid that expires on 11/2021.

The Effects of Lead Exposure brochure was issued and discussed. Assembly Bill 2370, which will require licensed Child Care Facilities to test their water for excessive amounts of lead. Testing will be required from January 1st, 2020 to January 1st, 2023 and must be conducted every five years from the initial testing.

LPA provided the Community Care Licensing website www.ccld.ca.gov, so the director can obtain updated licensing information, new regulations, self-assessment guides and access forms. LPA advised staff of their responsibility to stay current in regards to new regulations.

Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files. Report reviewed with director. Notice of Site Visit issued and must remain posted for 30 days. Appeal Rights also issued and discussed.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kristal Goodell	TELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: BUILDING KIDZ SCOTTS VALLEY	FACILITY NUMBER: 444415700
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/18/2021 Section Cited	1 2 3 4 5 6 7	Health-Related Services. All prescription and nonprescription medications shall be maintained with the child's name and shall be dated. During inspection LPA observed abled Epi-Pen unlabeled which poses an immediate risk to children in care
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kristal Goodell	TELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: BUILDING KIDZ SCOTTS VALLEY	FACILITY NUMBER: 444415700
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/02/2021 Section Cited	1 2 3 4 5 6 7	Fixtures, Furniture, Equipment and Supplies. All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids and/or conveniences shall be provided as needed in centers that serve children with physical disabilities. During inspection
	8 9 10 11 12 13 14	LPA observed LPA learned the children's restroom in the kinder classroom and sink in toddler classroom are out of service which poses a potential risk to children in care.	8 9 10 11 12 13 14
Type B 07/02/2021 Section Cited	1 2 3 4 5 6 7	Outdoor Activity Space. As a condition of licensure, the areas around and under high climbing equipment, swings, slides and other similar equipment shall be cushioned with material that absorbs falls. LPA observed ground visible in areas of the climbing structure where cushioning is required to observe a fall which poses a potential risk to children in care.
	1 2 3 4 5 6 7

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	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Kristal Goodell	TELEPHONE: (408) 489-9484
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC809 (FAS) - (06/04)

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