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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 274400369
Report Date: 10/06/2021
Date Signed: 10/06/2021 12:38:13 PM

Document Has Been Signed on 10/06/2021 12:38 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KING CITY COOPERATIVE NURSERY SCHOOLFACILITY NUMBER:
274400369
ADMINISTRATOR:MILLER, TANYAFACILITY TYPE:
850
ADDRESS:508 NORTH SECOND STREETTELEPHONE:
(831) 385-3577
CITY:KING CITYSTATE: CAZIP CODE:
93930
CAPACITY: 15TOTAL ENROLLED CHILDREN: 0CENSUS: 10DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Tanya MillerTIME COMPLETED:
12:45 PM
NARRATIVE
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On 10/06/2021 at 10:10 AM, Licensing Program Analyst (LPA), Susy Cervantes, conducted an annual visit to the facility and met with Tanya Miller, director, and explained the nature of today’s visit. LPA toured the Facility both inside and outside during today’s visit. LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Earthquake Preparedness Checklist (LIC 9148), Parents’ Rights Poster (PUB 393), Personal Rights (LIC 613A), Child Car Seat Law (PUB 269), Menus, and Activity Schedule.

A listing of staff criminal record clearances associated to this facility in the CCL Licensing Information System (LIS) on 10/04/2021 was reviewed; and it indicates that one volunteer that requires caregiver background clearance has not received criminal record and child abuse index clearances or exemptions.
LPA also reminded them of the applicable civil penalties for those adults who have not received fingerprint clearance, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violations within a 12 month period.

LPA observed the medical assessment and the Information and Emergency Information form (LIC 700) in 6 children’s files. LPA observed the required health screening in one staff file. Director has current CPR and First Aid Certifications that expire 08/01/23. Director understands that there shall be at least one person, with valid CPR and First Aid certifications, on site at all times or present during off-site activities (field trips). Director understands the conditions, limitations, and capacity specifications of the Facility license. Director understands that children shall be visually supervised at all times. LPA reviewed the sign-in, sign-out sheets for the past 30 days and took pictures of a Child Care Facility Roster (LIC 9040) and all were in compliance. LPA observed that the teacher/child ratio was in compliance during today’s visit. LPA observed one teacher and two parent volunteers with 10 children during today’s visit.

Continues on report dated 10/06/2021 pg. 1/2
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KING CITY COOPERATIVE NURSERY SCHOOL
FACILITY NUMBER: 274400369
VISIT DATE: 10/06/2021
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Continuation of report dated 10/06/2021 pg. 2/2

Drinking water is readily available for the children indoor and outdoors via water dispenser. LPA observed solid waste containers with tight-fitting lids in each room and in the playground area. Staff and children’s bathrooms are clean, sanitary, and operable. There is a separate staff bathroom not utilized by the children which an isolated child can use if needed. Director stated there are no weapons on the premises.

Facility has 2 half day programs and snack are brought in by parents. The food preparation area is adequately equipped with oven, refrigerators, and hot and cold running water. There is also adequate food for snacks and regular meals for the children. Cleaning supplies are inaccessible to the children and stored in the locked adult bathroom. Medication is not administered at the facility, parents must administer medications before or at the facility, medication at the facility is stored in a top kitchen cabinet.

LPA observed a disaster drill log that was last conducted on 11/2020. Smoke detector and carbon monoxide detector are operable. LPA observed a two 3A40BC fire extinguisher that were fully charged.

LPA observed all furniture and equipment are in operable condition. The playground area utilized by children is surrounded by appropriate fencing. LPA observed that the outdoor equipment is age appropriate and in good condition. There is also sufficient resilient material, rubber mulch, in the outdoor playground area. LPA did not observe any bodies of water.

LPA discussed the requirements of AB 633 with Director, Tanya Miller, and provided the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and they understand the requirements. LPA also discussed "zero tolerance" related regulations with the site supervisor and was advised of the assessment for an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected. Licensing Forms, Title 22 Regulations and Information can be obtained through the internet at www.cdss.ca.gov.

LPA conducted an exit interview with Director, Tanya Miller.
Type B deficiency cited during today's visit. NOTICE OF SITE VISIT WAS ISSUED AND MUST BE POSTED FOR 30 DAYS.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Susy Cervantes
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2021 12:38 PM - It Cannot Be Edited


Created By: Susy Cervantes On 10/06/2021 at 12:19 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KING CITY COOPERATIVE NURSERY SCHOOL
FACILITY NUMBER: 274400369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2021
Section Cited
CCR
101174(d)

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101174(d) Disaster and Mass Casualty Plan
Disaster drills shall be conducted at least every six months.
This requirement was not met as evidenced by:
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Director will conduct and document a disaster drill with the children in care and will submit proof of completion to the San Jose Regional Office by close of business on 10/20/2021.
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Based on record review, LPA observed a disaster drill log that was last conducted on 11/2020. This poses a potential risk to the health and safety of children in care.
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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:Mary Segura
LICENSING EVALUATOR NAME:Susy Cervantes
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021


LIC809 (FAS) - (06/04)
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