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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415767
Report Date: 07/20/2021
Date Signed: 07/21/2021 08:27:28 AM

Document Has Been Signed on 07/21/2021 08:27 AM - 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:CHILDREN'S COURTYARD, THEFACILITY NUMBER:
434415767
ADMINISTRATOR:SHAYLYNN LUCASFACILITY TYPE:
850
ADDRESS:610 E DUNNE AVENUETELEPHONE:
(408) 778-1977
CITY:MORGAN HILLSTATE: CAZIP CODE:
95037
CAPACITY: 96TOTAL ENROLLED CHILDREN: 0CENSUS: 45DATE:
07/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Teresa Addison and Annabelle CalasanzTIME COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Case Management- Deficiencies. LPA met with Teresa Addison, District Manager, and Annabelle Calasanz and explained the reason for the inspection. Present during today's inspection were 45 children and at least 9 staff.

LPA reviewed Facility Personnel Summary Report printed 07/19/2021. LPA observed that S-1, S-2, and S-3 were not associated to facility number. S-1 and S-2 have cleared criminal record and child abuse index, but is not associated to facility number. Director stated that she submitted the LIC 9182 for S-1 on 06/21/2021 to Sacramento, but was asked to transfer fingerprints through Guardians. S-2 is associated to the school age program, but not associated to this facility number. LPA observed that LIC 9182 was filled out for S-2, but there was no confirmation. Director sent LIC 9182 with a valid ID to Licensing during inspection to transfer S-1 and S-2's fingerprints. LPA discussed with Director to ensure that she is getting confirmation whenever she is sending LIC 9182.

S-3 got fingerprinted on 07/12/2021, but her fingerprints have not cleared. A copy of the Livescan was obtained during today's inspection. Director stated that S-3 started working on 07/19/2021. Director and District Manager stated that they will have S-3 conduct training until fingerprints are cleared. LPA discussed with District Manager and Director that all staff need to be fingerprint cleared before they start working.



-----------------------CONTINUES ON 809 DATED 07/20/2021 PAGE 2---------------------------
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2021
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: CHILDREN'S COURTYARD, THE
FACILITY NUMBER: 434415767
VISIT DATE: 07/20/2021
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-------------------CONTINUATION OF 809 DATED 07/20/2021 PAGE 1---------------------------

As a result of this inspection, two Type A citations were cited. A civil penalty of $200 and $500 were been assessed for Caregiver Background Check. An exit interview was conducted where this report, citation, civil penalties, and appeal rights were discussed and provided to Teresa Addison, District Manager, and Annabelle Calasanz, Director.

LPA also discussed about AB 633 requirement to provided a copy of 809 report dated 07/20/2021 and obtain a signed copy LIC 9224 for each child in care within one business day. LPA also discussed with Teresa Addison and Annabelle Calasanz that a copy of this report and a signed copy of LIC 9224 is required for any newly enrolled children within the 12 month period. LPA will email a copy of LIC 9224 and fact sheet to Teresa Addison and Annabelle Calasanz.

A Notice of Site Visit has been issued and must be posted for 30 days; along with a copy of this report.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2021 08:27 AM - It Cannot Be Edited


Created By: Samantha Yip On 07/20/2021 at 03:23 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: CHILDREN'S COURTYARD, THE
FACILITY NUMBER: 434415767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2021
Section Cited
CCR
101170(d)

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Criminal Record Clearance. All individuals subject to criminal record review shall, be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.
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By POC 07/21/2021, Director stated that S-3 will not return until her fingerprints are cleared.
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Based on record reviews, S-3 completed LiveScan on 07/12/2021. S-3's has not received cleared fingerprints prior to working at the center. This poses an immediate risk to the health and safety to the children in care.
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Type A
07/21/2021
Section Cited
CCR101170(e)(2)

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:Request a transfer of a criminal record clearance as specified in Section 101170(f)...
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Deficiency was corrected during today's inspection. Director sent LIC 9182 and a valid ID to Licensing (San Jose Regional Office) to transfer S-1's fingerprints.
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Based on record reviews, S-1 has fingerprint clearance, but fingerprints were not associated to faciltiy number. This poses an immediate risk to the health and safety to the 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:Anthony Studebaker
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2021


LIC809 (FAS) - (06/04)
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