Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070209920
Report Date: 03/15/2017
Date Signed 03/15/2017 02:05:04 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: 106DATE:
03/15/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Celina NgTIME COMPLETED:
02:15 PM
NARRATIVE
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LPA Dayna Collier met with Center Director Celina Ng for a case management visit as a result of receiving an unusual incident report. During the visit, interviews were conducted. An incident occurred when a group of boys began to play a game of throwing a pillow. One child became angry when he wasn't allowed to join the game. The angry child intentionally stabbed one of the boys in the arm with his pencil. Staff in the room supervising did not observe nor were aware of an incident until the boys informed them of the details. First aid was applied to the injured child and his parents were informed.

The attached type B deficiency is cited and must be corrected by the due date. This report must be available for public review for 3 years. An exit interview was conducted and the final report was reviewed with the director. Licensee was provided a copy of their appeal rights (LIC 9058 12/15) and the signature on this form acknowledges receipt of these rights.

A site visit notice was posted.
SUPERVISOR'S NAME: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: 510-725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2017
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SRVSACCA - KIDS COUNTRY-BOLLINGER CANYON
FACILITY NUMBER: 070209920
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2017
Section Cited
101229(a)(1)
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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).
ALTHOUGH STAFF WERE IN THE ROOM, STAFF FAILED TO OBSERVE AND INTERVENE WHEN AN INCIDENT OCCURRED THAT POSED A RISK TO CHILDREN IN CARE.
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POC: By 3/22/17, a written plan of action will be sent to Licensing detailing steps staff will take to ensure visual supervision at all times.
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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: Zakiya AliTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Dayna CollierTELEPHONE: 510-725-7021
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2017
LIC809 (FAS) - (06/04)
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