Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444412004
Report Date: 08/20/2015 12:00:00 AM
Date Signed 08/20/2015 09:34:08 AM

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:CAMPUS KIDS CONNECTION MOUNTAINFACILITY NUMBER:
444412004
ADMINISTRATOR:KELSEY FIERSFACILITY TYPE:
840
ADDRESS:3042 OLD SAN JOSE ROADTELEPHONE:
(831) 475-3274
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY:30CENSUS: 0DATE:
08/20/2015
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Barbara GriffinTIME COMPLETED:
10:00 AM
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Licensing Program Analyst Darryl Liu met with Barbara Griffin, executive director, for the purpose of conducting a capacity increase. This was in response to an application for a new license. The applicant/licensee is a nonprofit corporation, and Barbara is designated as the applicant for the license. Kelsey Fiers is designated as the site supervisor. The applicant has applied for a license requesting a capacity of 60 children, ages kindergarten to 6th grade, ambulatory only. The program will operate Monday thru Friday from and 12 P.M to 6 P.M. Children will attend the program half days.

The corporation owns a portable located on Mountain Elementary School, which is a functioning school site. Applicant is exempt from meeting square footage, and sink/toilet requirements. A capacity and approval of use letter from the School Superintendent was obtained. The capacity letter allows for 60 children. A fire clearance for the portable for capacity of 60 ambulatory children and the school fire clearance was also obtained.

There are two bathrooms for children's use located on the far side of the elementary school. The toilets are designated for boys and girls separately with stalls located inside the bathrooms for individual privacy.

All documents required to be posted and visible to parents were observed. Emergency Evacuation Procedures will be practiced at least monthly and documented. Discipline for children will be redirection. No corporal punishment is allowed. Care and Supervision of the children was discussed. Staff will sign children in upon arrival. Visual supervision of all of the children will be maintained at all times. The working telephone number on site is 831-475-3274. Transportation is not provided. Bodies of Water were not observed.



Report Continues on the next page:
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Darryl LiuTELEPHONE: 408-334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2015
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: CAMPUS KIDS CONNECTION MOUNTAIN
FACILITY NUMBER: 444412004
VISIT DATE: 08/20/2015
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Only cold water is available in the children's sinks in the portable and bathrooms. Sink with hot water is located in the teachers lounge/kitchen and this is where any dishwashing will occur. There is soap and disposable hand towels available for hand washing in the portable and bathrooms. There is a separate bathroom for staff located in the teachers lounge/kitchen. Bathroom for sick child will be the staff bathroom. The sick child will be isolated in the classroom separate from other children and there is a designated sick bed and bedding provided or secretaries office.. Windows have appropriate screens. Medications are administered at the facility and will are stored in a high cabinet in the kitchen or in a lock box in the refrigerator. All required First aid supplies are stored inaccessible to children in a locked box, and are located in the cabinet in the kitchen area. Snack is provided for the children and there is a kitchen in the staff lounge with a dishwasher and stove. There is a refrigerator in the portable. There is a garbage can with a tight fitting lid for solid waste disposal. There are 20 cubbies and 28 hooks, 5 tables, 31 chairs. There is age-appropriate equipment, supplies and toys for children. The rooms are adequately lit. Classroom temperatures will be maintained at least at 68 degrees. Poisons are locked. Detergents and cleaning supplies are stored separate from food and inaccessible to the children. There is a pad locked cabinet in the portable where these are located. Drinking water will be provided indoors by a drinking fountain and outdoors by a drinking fountain. There is four foot fencing around the playground. There is age appropriate equipment and toys on the playground. There is sand and woodchips for proper cushioning under climbing structures. Shade for the children on the playground will be provided by large shade structures.

Fingerprinting requirements and applicable civil penalties were discussed/reviewed. The staff at this facility must be fingerprinted and associated to this facility prior to employment/presence at the facility.

A license to operate an afterschool program for capacity of 60 children, all ambulatory, will be recommended effective 08/20/15.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Darryl LiuTELEPHONE: 408-334-8556
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2015
LIC809 (FAS) - (06/04)
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