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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070208035
Report Date: 08/15/2025
Date Signed: 08/15/2025 11:02:55 AM

Document Has Been Signed on 08/15/2025 11:02 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SRVSACCA - KIDS COUNTRY-GREENBROOKFACILITY NUMBER:
070208035
ADMINISTRATOR/
DIRECTOR:		MATT MONTEMAYORFACILITY TYPE:
840
ADDRESS:1531 ST. HELENA DRIVETELEPHONE:
(925) 831-8591
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 158TOTAL ENROLLED CHILDREN: 158CENSUS: 21DATE:
08/15/2025
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Kiki KardasisTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 8/15/2025 at approximately 09:00am, Licensing Program Analyst (LPA) Jamel Maiwandi conducted an unannounced Case Management inspection for an increase in capacity. Upon arrival, LPA met with Facility Representatives Kiki Kardasis, Marjan Sharokhani, and Ryan Gipson. Applicant Ann Tancioco was not present during this inspection. Applicant is requesting to be licensed for 228 school-age children, ages 3.9-12 years old and will operate in 2 portables, MPR, rooms 302,303,508 and a maximum of 35 children in rooms 501 and 607 each. Hours of operation are from 7:00am-6:30pm Monday-Friday. This is a school-age program located on the Greenbrook Elementary school site. Present during today’s inspection were 21 children with 5 staff. Appropriate ratios and supervision was observed. All indoor and outdoor activity space utilized for the children was inspected today. LPA informed facility representatives that staff are required to maintain direct visual supervision of the children at all times during indoor and outdoor activities.

LPA continued to tour the facility and observed all indoor activity space to be complete with safe, age-appropriate furniture and equipment, including tables, chairs, cubbies, bookshelves, and other activity supplies for the children. Drinking water is available in the classrooms via drinking fountains and water bottles. LPA observed all hazardous items to be inaccessible to children and reminded facility representatives to inspect daily for any potential hazards and safety concerns. There are no bodies of water or weapons on the property. Fire clearance was granted on 8/7/2025.

The facility currently has a fully fenced playground area. Fencing is made of wrought-iron and is at least four feet high. Shade is provided via multiple large awnings in the play area as well as shaded bench area.

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NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Jamel Maiwandi
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SRVSACCA - KIDS COUNTRY-GREENBROOK
FACILITY NUMBER: 070208035
VISIT DATE: 08/15/2025
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There are sufficient outdoor age-appropriate toys and play equipment available on the playground. There is a climbing structure on the playground for children ages 3 and above which is properly anchored. There is adequate cushioning in the play area provided by tanbark. Drinking water is available via children’s water bottles and fountains. LPA observed all hazardous items on the playground to be inaccessible to children. Facility Reps were reminded that any changes to the facility must be reported to and approved by Community Care Licensing.

For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP).


Facility representatives were reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Facility Representatives were informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.



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NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Jamel Maiwandi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SRVSACCA - KIDS COUNTRY-GREENBROOK
FACILITY NUMBER: 070208035
VISIT DATE: 08/15/2025
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

No corrections are needed. A license for 228 children will be granted upon a final file review.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with facility representatives Kiki Kardasis and Ryan Gipson and Marjan Sharokhani..
NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Jamel Maiwandi
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2025
LIC809 (FAS) - (06/04)
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