Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413591
Report Date: 08/28/2015 12:00:00 AM
Date Signed 08/28/2015 12:43:22 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:CAMPBELL CHILD DEVELOPMENT CENTERFACILITY NUMBER:
434413591
ADMINISTRATOR:ELLEN WILLIAMSFACILITY TYPE:
830
ADDRESS:1063 FEWTRELL DRIVETELEPHONE:
(408) 371-9310
CITY:CAMPBELLSTATE: CAZIP CODE:
95008
CAPACITY:9CENSUS: 6DATE:
08/28/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Andrea GelenterTIME COMPLETED:
01:00 PM
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3) Licensing Program Analyst (LPA), Esther Adeyemi, conducted an unannounced random visit to the Facility today. LPA met with director Andrea Gelente and explained the nature of today's visit to her. LPA toured the Facility both inside and outside during today's visit. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents' Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), snack Menus, and Activity Schedule.

A review of staff records on 08/27/15 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded director of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violations within a 12 month period.

LPA reviewed 6 children's and 2 staff files during today's visit. Each child's file reviewed contains the Information and Emergency Information form (LIC 700). The staff files reviewed contains the required transcripts/verification of experience. Director has current CPR and First Aid certifications on file. Director understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips).

LPA observed that the teacher/child ratio was in compliance during today's visit. Director understands the conditions, limitations, and capacity specifications of the Facility license. Director understands that children shall be visually supervised at all times.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Esther AdeyemiTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2015
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: CAMPBELL CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 434413591
VISIT DATE: 08/28/2015
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LPA observed that all rooms are clean and safe for all children and staff. LPA observed solid waste containers with tight-fitting lids throughout the Facility. classroom is clean, sanitary, and operable.
Director states that there are no weapons or firearms on the premises. The food preparation and storage areas are clean. Each infant has personal items individually stored and labeled. LPA observed diaper changing table and procedures are appropriate. Infant Needs and Service Plan are up to date. Cleaning supplies are stored away from children. Medication(s) at the Facility will be stored in the director's office.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by toddler children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. Drinking water is readily available for the toddler children in the outdoor playground area, coolers and pitchers/disposable cups are available for the toddler children. LPA observed that the outdoor equipment is age appropriate and in good condition. There is sufficient resilient materials in the outdoor playground area.
LPA did not observe any bodies of water.

LPA discussed the requirements of AB 633 with the licensee and provided the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understand the requirements. LPA also discussed "zero tolerance" related regulations with the licensee and advised her of the assessment of an immediate $150 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $150 per day continues until the violation(s) is corrected.

No deficiencies cited.

Licensing Forms, Title 22 Regulations and information can be obtained through the internet at www.cdss.ca.gov.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Esther AdeyemiTELEPHONE: (408) 335-9890
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2015
LIC809 (FAS) - (06/04)
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