Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444412004
Report Date: 09/29/2016
Date Signed 09/29/2016 03:24:10 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: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:60CENSUS: 17DATE:
09/29/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Barbara GriffinTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA), Mel Matos, conducted an unannounced random visit to the Facility today. LPA met with Barbara Griffin, Licensee representative, and explained the nature of today's visit to her. LPA toured the Facility both inside and outside during today's visit. LPA notes that the Facility is located on the campus of Mountain Elementary School in Portable 18-A and 18-B (located on the back of campus). Hours of operation: 12 PM to 6 PM. Barbara states that Brittany Waterman is the new facility director and pertinent director paperwork was submitted to LPM Sandy Knight prior to 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), and Activity Schedule.

A review of staff records on September 29, 2016 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 Barbara 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 notes that all fingerprint clearances are associated to primary license #440710576**.

LPA reviewed ten children's and two staff files during today's visit. Each child's file reviewed contains the Information and Emergency Information form (LIC 700). All staff files reviewed contain the required transcripts/verification of experience. Brittany and one teacher has current CPR and First Aid certifications on file. Barbara 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. Barbara understands the conditions, limitations, and capacity specifications of the Facility license. Barbara understands that children shall be visually supervised at all times. LPA observed the director and one teacher with 17 children in the Facility during today's visit. The Facility is aware of the required sign in and sign out procedures for school age children.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 09/29/2016):
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2016
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 09/29/2016
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 09/29/2016):

LPA observed that all rooms are clean and safe for all children and staff. Barbara states that the Facility has a third-party cleaning service that cleans the Facility Monday through Friday in the evenings. Drinking water is readily available for the children in each room and in the outdoor playground area via drinking fountains. LPA observed solid waste containers with tight-fitting lids in the Facility. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Barbara states that there are no weapons or firearms on the premises.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. Cleaning supplies are inaccessible to the children and stored in high cabinets inaccessible to children. Any medications at the Facility are stored in a locked medication box in the cabinet inaccessible to the children. Barbara states that the Facility is not administering and medications at this time. LPA advised the Licensee of the requirement of the new immunization requirement (pertussis, measles, and flu vaccines) for all Licensees and staff that work directly with the children.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground areas utilized by children are surrounded by appropriate fencing and the outdoor surfaces are safe for the 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.

No deficiencies issued during today's visit.

Licensing Forms, Title 22 Regulations and information can be obtained through the internet at www.cdss.ca.gov.
LPA conducted an exit interview with Barbara and requested that she submit an updated Personnel Report (LIC 500) and Emergency Disaster Plan (LIC 610) to LPA by Friday October 7, 2016.


A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2016
LIC809 (FAS) - (06/04)
Page: 2 of 2