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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073402700
Report Date: 11/03/2022
Date Signed: 11/03/2022 02:41:08 PM

Document Has Been Signed on 11/03/2022 02:41 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:BUENA VISTA CLUBFACILITY NUMBER:
073402700
ADMINISTRATOR:CARL MORIMOTOFACILITY TYPE:
840
ADDRESS:2372 BUENA VISTA AVENUETELEPHONE:
(925) 930-0272
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY: 170TOTAL ENROLLED CHILDREN: 170CENSUS: 13DATE:
11/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:CARL MORIMOTOTIME COMPLETED:
03:00 PM
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On 11/3/22 Licensing Program Analyst (LPA) Monica Mathur conducted an unannounced Annual inspection at Buena Vista Club. LPA met with Director, Carl Morimoto and explained the purpose of today's inspection. Located in the premises of Buena Vista Elementary. Facility's operating days and hours
M, T, Th, F - 7am-9am & 12:55pm-6pm
Wed - 7am-8:50am & 12:15pm-6pm
3 Rooms - Main, Side & Back building. At time of inspection, there were 13 children in the main building.
The physical plant was inspected. LPA toured the premises with the Director.
Indoor space: Facility was observed to be in compliance with school age regulation requirements. The classrooms, restrooms, food storage areas and spaces accessible to children were inspected. Disinfectants, cleaning solutions, poisons and other items that are dangerous to the health and safety of children were stored in places inaccessible to them. Storage areas for poisons were locked and medications were kept in a safe place inaccessible to children. Cabinets, drawers, and rooms used for storage were locked. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. Restrooms for children were observed to be in safe, sanitary, and functioning condition. Floors were clean and free from tripping hazard. Foods and beverages were stored safely. Food storage area were clean, free of litter, rubbish, and rodents/vermin. Trash cans for solid waste had tight-fitting covers on and were in good repair. LPA observed a working Fire extinguisher, Smoke and Carbon Monoxide Detectors, fire pull stations, and sprinkler system.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: BUENA VISTA CLUB
FACILITY NUMBER: 073402700
VISIT DATE: 11/03/2022
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Outdoor Space: Outdoor playground was fenced and safe. The play equipment was maintained in good condition and free of hazards. Areas around and under high climbing equipment and slides were cushioned with material that absorbs falls.
File Review: Children sign in and out procedures and logs were reviewed. All children were signed in and in compliance with the school age sign in/out procedures. A sample of Children and Staff files was taken for review. All files contained required documents. There was at least one staff present with current certification in Pediatric CPR and First Aid at the facility during inspection. Children's Roster LIC 9040 and Personnel Report LIC500 was reviewed, and a copy obtained. Last Fire Drill was conducted in Oct 2022.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (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

Director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

In the areas that were evaluated, no regulatory violations were observed.
Exit interview conducted and report was reviewed with the Director, Carl Morimoto. A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Monica Mathur
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC809 (FAS) - (06/04)
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