<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070206070
Report Date: 01/09/2023
Date Signed: 01/09/2023 02:00:40 PM

Document Has Been Signed on 01/09/2023 02:00 PM - It Cannot Be Edited

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:KING'S VALLEY PRESCHOOLFACILITY NUMBER:
070206070
ADMINISTRATOR:KETNER, MICHELEFACILITY TYPE:
850
ADDRESS:4255 CLAYTON ROADTELEPHONE:
(925) 687-2020
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY: 120TOTAL ENROLLED CHILDREN: 79CENSUS: 54DATE:
01/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Michelle KetnerTIME COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 1/9/23 at 1:45 pm Licensing Program Analyst (LPA) Monica Mathur conducted a Case Management inspection at King's Valley Preschool and met with Director, Michelle Ketner.

During the course of a complaint investigation, it was determined that on 12/12/22 a child C1 got wet playing outside and went home in wet clothes. At least 2 staff members present at closing time were aware C1 was wet, but failed not inform C1's parent about the incident and were not provided any explanation on how C1 got wet and why child was not changed into dry clothes. This is a violation of California Code of Regulations Title 22 Reporting Requirements resulting from lack of communication with parents; and posed a potential risk to health and safety of children in care. Deficiency is cited on 809-D page.

This report was reviewed with Director, Michelle Ketner. NOTICE OF SITE VISIT WAS ISSUED, MUST BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2023
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
Document Has Been Signed on 01/09/2023 02:00 PM - It Cannot Be Edited


Created By: Monica Mathur On 01/09/2023 at 01:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: KING'S VALLEY PRESCHOOL
FACILITY NUMBER: 070206070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/16/2023
Section Cited
CCR
101212(f)

1
2
3
4
5
6
7
101212 Reporting Requirements (f) The items specified in (d)(1)(A) through (H) shall also be reported to the child's authorized representative. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
By POC Due Date 1/16/23 Director agreed to:
1.submit written plan on steps taken to ensure regulation compliance
8
9
10
11
12
13
14
Per investigation, at least 2 staff were aware C1 was wet and did not have dry change of clothes. Staff failed to inform or provide explanation to parent at pick up about the incident. This posed a potential risk to health/safety of child/ren in care.
8
9
10
11
12
13
14
2. conduct staff meeting to discuss this regulation, steps put in place and send to CCL proof of training.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Sherelle Johnson
LICENSING EVALUATOR NAME:Monica Mathur
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2