<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416102
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:18:27 PM

Document Has Been Signed on 10/11/2022 03:18 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:
354416102
ADMINISTRATOR:ALMA MAY BAYANI, PSYDFACILITY TYPE:
830
ADDRESS:331 GATEWAY DRIVETELEPHONE:
(831) 635-9284
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 20TOTAL ENROLLED CHILDREN: 16CENSUS: 12DATE:
10/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Cristina BarrientosTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Deanna Villagrana, conducted an unannounced required one year visit to the Facility today. LPA met with director, Cristina Barrientos and explained the nature of today's visit to her. The infant room is located in the caterpillar room of the facility. The playground area of the Facility is located behind the classroom.

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 10/04/2022 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 five staff (1 director, 2 teachers and 2 aides) files during today's inspection. Staff 3 is missing MMR immunization. Staff 4 and 5 are missing Mandated Reporter training. Child 10 is missing Physician's Report. Child 8, 9 and 10 are missing immunization records or need to be updated. No staff had a current CPR/First Aid certificate. 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). Two staff files (director & 4 teachers) reviewed contain the required transcripts/verification of experience.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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 6
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: 354416102
VISIT DATE: 10/11/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA discussed the safe sleep regulations with Director Cristina Barrientos and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Director Cristina Barrientos of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA observed that the teacher/child ratio was in compliance during today's visit. LPA observed 12 infants with one teacher and two aides in the classroom. 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 both rooms are clean and safe for all children and staff. Cristina states the rooms are cleaned daily by custodial service nightly. One staff member cleans and disinfect the rooms along with shampooing carpets every five months. During visit, LPA was made aware that the facility has had several outbreaks of hand, foot mouth and did not notify the Department. Drinking water is readily available for the children in each room and in the outdoor playground area via pitchers/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 the director's office area. No IMS is administered by the Facility.

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 and tarp provide shade for the infants. LPA did not observe any bodies of water.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: 354416102
VISIT DATE: 10/11/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.


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

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/11/2022 03:18 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/11/2022 at 02:53 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: 354416102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022

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 3 is missing MMR immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2022
Plan of Correction
1
2
3
4
Director will submit MMR immunization for staff 3 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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Staff 4 and 5 are missing Mandated Reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2022
Plan of Correction
1
2
3
4
Director will submit completed Mandated Reporter training certificate for staff 4 and 5 to CCLD by POC date.
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: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/11/2022 03:18 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/11/2022 at 02:53 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: 354416102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(f)
Personnel Requirements
(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

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. No staff had a current CPR/First Aid certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2022
Plan of Correction
1
2
3
4
Director will submit CPR/1st Aid for at least one staff member in the infant room to CCLD by POC date.
Type B
Section Cited
CCR
101220(a)
Child's Medical Assessments
(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child.

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. Child 10 is missing Physician's Report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2022
Plan of Correction
1
2
3
4
Director will submit Physician's Report for child 10 to CCLD by POC date.
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: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 10/11/2022 03:18 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 10/11/2022 at 02:53 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: 354416102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220.1(g)
Immunizations
(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled.

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. Child 8, 9 and 10 are missing immunization records or need to be updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2022
Plan of Correction
1
2
3
4
Director will submit immunizations for child 8, 9 and 10 to CCLD by POC date.
Type B
Section Cited
CCR
101212(d)


This requirement is not met as evidenced by: Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above. During visit, LPA was made aware that the facility has had several outbreaks of hand, foot mouth and did not notify the Department which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2022
Plan of Correction
1
2
3
4
Director will submit a statement stating she has read and understands regulation to CCLD by POC date.
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: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022


LIC809 (FAS) - (06/04)
Page: 6 of 6