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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416101
Report Date: 06/17/2021
Date Signed: 06/17/2021 01:14:21 PM

Document Has Been Signed on 06/17/2021 01:14 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:HOLLISTER CHILD DEVELOPMENT CENTER, LLCFACILITY NUMBER:
354416101
ADMINISTRATOR:ALMA MAY BAYANI, PSYDFACILITY TYPE:
850
ADDRESS:331 GATEWAY DRIVETELEPHONE:
(831) 635-9284
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 30TOTAL ENROLLED CHILDREN: 0CENSUS: 22DATE:
06/17/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Alma May BayaniTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with director Cristina Barrientos for a case management visit. LPA observed one teacher with 14 children in the large playground next to the preschool room and eight children with one teacher in the small playground behind the preschool. Director May Bayani arrived several hours later.

LPA observed teacher Esperanza alone with 14 children in the large playground to the right of the preschool. Esperanza was helping children use the restroom near the playground and supervised kids on a large playground. Facility was out of ratio.

The following type A deficiency was cited on the attached page (809-D). Director was informed that failure to correct the deficiency by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

An exit interview was conducted and Plans of Corrections were reviewed and developed with the Director. A copy of this report and appeal rights were discussed and left with May, whose signature on this form confirms receipt of these documents.

A Notice of Site was issued and must be posted for 30 days.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/17/2021 01:14 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 06/17/2021 at 12:31 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: HOLLISTER CHILD DEVELOPMENT CENTER, LLC
FACILITY NUMBER: 354416101

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2021
Section Cited
CCR
101216.3

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There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below. This requirement was not met as evidenced by LPA observed teacher Esperanza alone with 14 children in the large playground to the right of the preschool.
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Director will submit a plan how she will remain in ratio and have each teacher read and sign it. Plan must be submitted to LPA by 06/18/2021.
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This poses an immediate risk to the Health, Safety or Personal Rights to 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:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2021


LIC809 (FAS) - (06/04)
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