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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444410610
Report Date: 12/15/2020
Date Signed: 03/17/2021 08:11:16 AM

Document Has Been Signed on 03/17/2021 08:11 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:COMMUNITY BRIDGES FAIRGROUNDS CHILD DEV CENTERFACILITY NUMBER:
444410610
ADMINISTRATOR:AMY RATHERFACILITY TYPE:
850
ADDRESS:2667 EAST LAKE AVENUETELEPHONE:
(831) 786-9621
CITY:WATSONVILLESTATE: CAZIP CODE:
95076
CAPACITY: 45TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/15/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Amy RatherTIME COMPLETED:
01:00 PM
NARRATIVE
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A follow up virtual visit conducted with Amy Rather, Site Supervisor via Zoom. Purpose of the visit is to clarify some information perviously provided with Amy and to deliver the finding of the investigation regarding a self reported incident where a child walked home alone without staff knowledge.
Please see next page for violation cited under Title 22. .
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Mahvash Behbood
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 03/17/2021 08:11 AM - It Cannot Be Edited


Created By: Mahvash Behbood On 12/15/2020 at 11:49 AM
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: COMMUNITY BRIDGES FAIRGROUNDS CHILD DEV CENTER
FACILITY NUMBER: 444410610

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2020
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision- Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). This requirement was not met as evidence by:
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Director will submit a plan to ensure children
are supervised at all times. this plan should include training on the subject. The plan must be received no later than 12/22/20. An immediate civil penalty of $500 was assessed.
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a self reported incident occurred on 11/13/20. A child walked home without staff knowledge, parent called facility to notify the center. This pose an immediate risk to health and safety of 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:Mahvash Behbood
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2020


LIC809 (FAS) - (06/04)
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