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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416101
Report Date: 11/10/2022
Date Signed: 11/10/2022 12:47:53 PM

Document Has Been Signed on 11/10/2022 12:47 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: 34CENSUS: 24DATE:
11/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Cristina BarrientosTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA), Deanna Villagrana, conducted an unannounced required one year inspection to the Facility today. LPA met with director, Cristina Barrientos and explained the nature of today's visit to her. The Facility is licensed in the Bumblebees, Fireflies, and Grasshoppers room ath the facility. The playground area of the Facility is located to the right of Bumblebees room. There is an additional playground on the left side of the building that Cristina states they are currently not using until surface is updated.

LPA toured the Facility both inside and outside for today's inspection. 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, Menus, and Activity Schedule.

A review of staff records on 11/07/2022 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions Director Cristina Barrientos 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.


LPA reviewed ten children's and four staff (three teachers and one aide) files during today's inspection. All children's files were complete and had current immunization records on file. Staff 4 is missing measles immunization record. Staff 4 does not have a valid TB test on File. Staff 4 Mandated Reporter certificate expired 08/10/2022. All four staff have current CPR and First Aid certifications on file. All three teachers reviewed contain the required transcripts/verification of experience. Cristina 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).
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: HOLLISTER CHILD DEVELOPMENT CENTER, LLC
FACILITY NUMBER: 354416101
VISIT DATE: 11/10/2022
NARRATIVE
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LPA observed that the teacher/child ratio was in compliance during today's visit. LPA observed six preschool children with one teacher in Bumblebee room, seven preschool children with one teacher in the Fireflies room and 10 preschool children with one teacher in the Grasshoppers room. An Aide entered the room shortly. One child was with Director Cristina and was picked up during walk through. Cristina understands the conditions, limitations, and capacity specifications of the Facility license. Cristina understands that children shall be visually supervised at all times. LPA observed that all rooms are clean and safe for all children and staff. Cristina states that one Facility staff cleans the facility and there is a janitorial service that cleans after hours. Drinking water is readily available for the children in each room and in the outdoor playground area via water dispensers/disposable cups. LPA observed solid waste containers with tight-fitting lids in the Facility. Staff and children's bathrooms are clean, sanitary, and operable. There is a separate staff toilet not utilized by the children which an isolated child can use if needed. Cristina states that there are no weapons or firearms on the premises.

The food preparation and storage areas are clean, free of litter & rubbish, and free of rodents and other vermin. All food and beverages that require refrigeration are stored in covered containers at 45 degrees F or less. Cleaning supplies are inaccessible to the children and stored in high cabinets inaccessible to children. Any poisons are stored in locked storage cabinets. Any medications at the Facility are stored in each classroom child is in. The facility has one child that requires inhaler at this time.

LPA observed all furniture and equipment is in good condition and safe for the children. The playground area utilized by children is surrounded by appropriate fencing and the outdoor surfaces are safe for the children. LPA observed that the outdoor equipment is age appropriate and in good condition. Building overhang provides shade for the day care children. LPA did not observe any bodies of water.

Exit interview conducted and report was reviewed with the Director Cristina Barrientos.


The following type B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies 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.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
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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: HOLLISTER CHILD DEVELOPMENT CENTER, LLC
FACILITY NUMBER: 354416101
VISIT DATE: 11/10/2022
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A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/10/2022 12:47 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 11/10/2022 at 12:27 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: 11/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Staff 4 is missing measles immunization record which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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2
3
4
Director Cristina will submit measles immunization for staff 4 to CCLD by POC date.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above. Staff 4 Mandated Reporter certificate expired 08/10/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2022
Plan of Correction
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2
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4
Staff 4 completed Mandated Reporter training during visit. Deficiency cleared today.
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: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/10/2022 12:47 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 11/10/2022 at 12:27 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: 11/10/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)(12)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Tuberculosis test documents as specified in Section 101216(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Staff 4 does not have a valid TB test on File which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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2
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4
Director Cristina will submit a valid TB test for staff 4 to CCLD by POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022


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