Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070209920
Report Date: 02/12/2016
Date Signed 02/12/2016 09:05:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SRVSACCA - KIDS COUNTRY-BOLLINGER CANYONFACILITY NUMBER:
070209920
ADMINISTRATOR:NG, CELINAFACILITY TYPE:
840
ADDRESS:2300 TALAVERA DRIVETELEPHONE:
(925) 275-0574
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:126CENSUS: 14DATE:
02/12/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Rowena AlegreTIME COMPLETED:
09:15 AM
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Licensing Program Analyst, Jason Jang made an annual random visit to the facility. LPA Jang met with the Assistant Site Director, Rowena Alegre. The buildings and grounds were inspected for health and safety which included the classrooms, outdoor play area and restrooms. The facility has correctly posted their license, parent's rights form, car seat law, and snack menu. At least one staff member had a first aid and pediatric CPR certificate. The first aid kit, sign in sign out sheet, and fire drill log were reviewed and found to be complete. Children and staff files were reviewed and found to be complete. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. Incidental Medical Services were discussed with the licensee. The licensee is not providing IMS (Incidental Medical Services) at this time. Licensee will submit an updated plan of operation if in the future they provide any IMS services to a child in care.
SUPERVISOR'S NAME: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2016
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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