Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430710194
Report Date: 08/29/2016
Date Signed 08/29/2016 04:11:21 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:BARRON PARK KIDS' CLUBFACILITY NUMBER:
430710194
ADMINISTRATOR:MITCHELL, KANDICEFACILITY TYPE:
840
ADDRESS:800 BARRON AVE.TELEPHONE:
(650) 856-1220
CITY:PALO ALTOSTATE: CAZIP CODE:
94306
CAPACITY:80CENSUS: 37DATE:
08/29/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:KandiceTIME COMPLETED:
04:30 PM
NARRATIVE
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A case management visit was made to the facility regarding the self reported incident. The incident occurred on 05/16/2016 and stated that a child was left behind in the bathroom.
According to incident report and Kandice's statement a teacher took seven children to school's bathroom. After the children were done, they ran to portable and staff person ran after them and forgot to do the head count.
A minute later, a child came to the class room and stated that staff person left her behind and she was in the bathroom by herself.
This is a violation of Zero tolerance and civil penalty of $150 was assessed.
The following type A deficiency is cited.
NOTICE OF SITE VISIT WAS POSTED. NOTICE MUST BE UP FOR 30 DAYS.
SUPERVISOR'S NAME: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2016
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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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: BARRON PARK KIDS' CLUB
FACILITY NUMBER: 430710194
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2016
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).
A 4th grader child was left in the school's bathroom without any visual supervision.
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A written plan of correction is requested by the due date. The plan should clearly identify steps to prevent such incident from reoccurring in future.
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THIS REPORT MUST BE GIVEN TO ALL CURRENT AND FUTURE PARENTS AND THEY NEED TO SIGN LIC 9224 FOR ONE YEAR FROM TODAY'S DATE.
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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: Timetra FaulconTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Roya ShahkaramiTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2016
LIC809 (FAS) - (06/04)
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