Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070209920
Report Date: 03/22/2016
Date Signed 03/22/2016 01:35:20 PM

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: 18DATE:
03/22/2016
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Celina Ng, DirectorTIME COMPLETED:
02:00 PM
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LPA Anika Evans met with Director Celina Ng for the purpose of an unannounced case management visit to add the Library on as usable rooms. This facility is housed on a functioning school site, ( Bollinger Elementary School), Kids Country located in the back of the property in 1 standing building.
An application was initially received to increase the capacity, but was rescinded and only wanted to add a room to the existing license capacity of 126. An approved fire clearance was signed 1/25/16 for a capacity of 126 providing care for school aged children ages kindergarten- 12yrs old in one building , 2 classrooms, the auditorium and the library.
A tour of the library was taken and found to be in accordance and compliance with regulations.

A review showed LPA Jang just conducted an annual inspection in February 2016.

There are no deficiencies cited at this visit.
This facility is recommended for being licensed adding the new space usage of the school Library.

A copy of this report will be on file for a period of three years for pubic review
A notice of site visit was posted and must remain posted for a period of 30 days for parental review
Appeal rights were reviewed and a copy given for use if needed at a later date
SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Anika EvansTELEPHONE: (510) 622-2626
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2016
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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