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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402545
Report Date: 03/15/2024
Date Signed: 03/15/2024 02:37:49 PM

Document Has Been Signed on 03/15/2024 02:37 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CONTRA COSTA COUNTY CSB GEORGE MILLER CENTERFACILITY NUMBER:
073402545
ADMINISTRATOR:JENNIFER KIRBYFACILITY TYPE:
830
ADDRESS:3068 GRANT STTELEPHONE:
(925) 646-5801
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY: 52TOTAL ENROLLED CHILDREN: 52CENSUS: 4DATE:
03/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:JENNIFER KIRBYTIME COMPLETED:
02:45 PM
NARRATIVE
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On March 15, 2024 Licensing Program Analyst (LPA) Tasha Alexander met with Site Supervisor I Rose Ann Ramiro and Site Supervisor III Jennifer Kirby to discuss a self reported Unusual Incident that occurred on 3/7/24, when a child opened a closet door where toys are placed and the door closed behind the child. The child was inside of the closet for approximately 28 seconds and was not harmed.

Please see the attached 809-d for citation.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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Document Has Been Signed on 03/15/2024 02:37 PM - It Cannot Be Edited


Created By: Tasha Hackett-Alexander On 03/15/2024 at 01:59 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: CONTRA COSTA COUNTY CSB GEORGE MILLER CENTER
FACILITY NUMBER: 073402545

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
101229(a)!1)

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101229 Responsibility for Providing Care and Supervision

101229 Responsibility for Providing Care and Supervision



(a) The licensee shall provide care and supervision as necessary to meet the children's needs.
(1) No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Per licensee, a meeting was held with staff about the importance of child supervision and the door handle will be replaced with a self locking handle that will require a key to open.
Licensee will also conduct a refresher zoning training with staff to ensure visual supervision of children inside of the classroom at all times. Licensee will submit a summary of the staff training to Community Care Licensing by 3/29/24
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THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY INTERVIEWS WHICH REVEALED AN INCIDENT WHERE A CHILD OPENED A CLOSET WHERE TOYS ARE PLACED AND THE DOOR CLOSED BEHIND THE CHILD. THE CHILD WAS INSIDE OF THE CLOSET FOR APPROXIMATELY 28 SECONDS AND WAS NOT HARMED.
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024


LIC809 (FAS) - (06/04)
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