Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070209920
Report Date: 06/28/2016
Date Signed 06/28/2016 02:09:03 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:120CENSUS: 40DATE:
06/28/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Celina NgTIME COMPLETED:
02:30 PM
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(1) Annual random visit conducted by Licensing Program Analyst, Jason Jang. LPA Jang met with the Director, Celina Ng. A tour of the facility was made and the buildings and grounds were inspected. All of the correct postings were on the wall. The sign in sign out sheet, first aid kit, snack menu, and fire drill log book were reviewed and found to be complete. Children and staff files were reviewed. Staff had a current CPR and first aid certificate. Licensee was reminded that anyone working at the facility must be fingerprint cleared prior to being in the presence of children, or an immediate civil penalty can be assessed. Also discussed: nutrition education; the new appeal process; and documents to be provided to parents/legal guardians. This facility provides Incidental Medical Services-IMS. LPA reviewed the storage of medication and equipment and supplies, and reviewed children’s, personnel, and administrative records. Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates. Exit interview was conducted. Licensee was provided a copy of their appeal rights. Notice of site visit was posted at the time of the inspection, and must remain posted for 30 days.

There were no deficiencies cited in today's visit.
SUPERVISOR'S NAME: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2016
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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