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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444400073
Report Date: 08/20/2024
Date Signed: 08/20/2024 04:03:00 PM

Document Has Been Signed on 08/20/2024 04:03 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MAIN STREET CKC INC.FACILITY NUMBER:
444400073
ADMINISTRATOR/
DIRECTOR:		TRAVIS SKELTONFACILITY TYPE:
840
ADDRESS:3400 MAIN STREETTELEPHONE:
(831) 475-5758
CITY:SOQUELSTATE: CAZIP CODE:
95073
CAPACITY: 80TOTAL ENROLLED CHILDREN: 66CENSUS: 4DATE:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Travis Skelton and Chrystina ButtreyTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mandeep Kaur and Licensing Program Manager(LPM), Belinda Devall, met with Director, Travis Skelton and Assistant Director, Chrystina Buttrey for an unannounced case management investigation. Purpose of today's investigation discussed: an incident report that the Facility self reported to the Department. The incident occurred on 07/24/2024. Upon LPA and LPM arrival, present were Director and Assistant Director with four children.

During today's investigation, LPA interviewed Assistant Director and Director.

Later, Regional Director, Kylie Roberts joined during today's investigation.

The investigation comprised of interviews, observations, and documents review. LPA toured the outdoor areas of the facility where the bathrooms are, with Director, Travis Skelton. Director, Assistant Director and Regional Director states that there is no set schedule for teachers to be in charge of bathroom walks during summer camp. Regional Director, Director and Assistant Director stated that any staff who was present at the facility on 07/24/2024 did not observe the incident. Facility was notified of the incident that occurred on 07/24/2024 by the parent of children (C6 and C7) on 07/25/2024 morning. Director, Regional Director and Assistant Director states that there was a Teacher assistant(S4) hired during summer camp for bathroom walks, but no one is aware of either Teacher assistant(S4) or any other staff was present during the bathroom walk on the day of the incident occurred on 07/24/2024 with children(C5,C6 and C7).

As a result of this investigation, LPA and LPM conclude that there was a lack of supervision for the children (C5,C6 and C7) as there is no evidence provided that a staff was present with the children(C5,C6 and C7) during bathroom walk on 07/24/2024. Therefore, one "Type A deficiency is issued today on the attached 809-D. Exit interview conducted and report was reviewed with Regional Director, Kylie Roberts and copy of appeal rights was provided. A notice of site visit has been issued and must remain posted for 30 days.

**Continue on 809-C**
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: MAIN STREET CKC INC.
FACILITY NUMBER: 444400073
VISIT DATE: 08/20/2024
NARRATIVE
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**Continuation from 809**

LPA informed Regional Director that this report dated 08/20/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Assembly bill 633 was provided and discussed with Regional Director. LPA informed the Regional Director to provide a copy of this licensing report dated 08/20/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224), must be placed in the child's file for verification.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/20/2024 04:03 PM - It Cannot Be Edited


Created By: Mandeep Kaur On 08/20/2024 at 03:10 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: MAIN STREET CKC INC.
FACILITY NUMBER: 444400073

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/21/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision: (a)The licensee shall provide care and supervision as necessary to meet the children's needs.(1)No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
This requirement was not met as evidenced by:
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Site Director stated that she is going to submit the written plan to make sure no child is left without the supervision of a teacher at any time including escorting children to the bathroom and assigned roles and responsibility of staff when assisting children including excorting children to the bathroom.
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Based on interviews, records review and self reported incident report, staff was not present with children(C5,C6 and C7) during bathroom walk. This poses an immediate risk to the health, safety and personal rights of children in care.
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Random samples of A signed acknowledgement of Receipt of Licensing Report (LIC9224) by the currently enrolled parents, will be submitted to department by 08/21/2024.

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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:Belinda Devall
LICENSING EVALUATOR NAME:Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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