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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 070208893
Report Date: 01/20/2023
Date Signed: 01/20/2023 02:24:54 PM

Document Has Been Signed on 01/20/2023 02:24 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:SRVSACCA - KIDS COUNTRY-VISTA GRANDEFACILITY NUMBER:
070208893
ADMINISTRATOR:GRAVELYN, JEANETTEFACILITY TYPE:
840
ADDRESS:667 DIABLO ROADTELEPHONE:
(925) 837-0330
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY: 120TOTAL ENROLLED CHILDREN: 111CENSUS: 24DATE:
01/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ann TanciocoTIME COMPLETED:
02:30 PM
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On 1/20/23 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Case Management inspection at SRVSACCA Kids Country Vista Grande. Director, Jeannette Gravelyn was not at the facility, and LPA met with Executive Director, Ann Tancioco.

During a case management inspection on 12/21/22, facility was cited one Type A deficiency with civil penalties for repeat violation due to absence of supervision where a child wandered away from facility. Facility has submitted plan of corrections and implemented several checks and procedures. Today, LPA conducted a walk through with Ann Tancioco, observed and reviewed corrections made and procedures put in place. Citation of 12/21/22 was cleared during inspection today and Letter of Clearance provided.

This report was reviewed with Executive Director, Ann Tancioco and Assistant Director, Katie Whitehouse and Notice of Site Visit provided which must be posted for 30 consecutive days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/20/2023
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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