030319700-3-3-2022-53-CC-ASRN-CC6RP6-20220303121124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 030319700
Report Date: 03/03/2022
Date Signed: 03/03/2022 12:11:38 PM

Document Has Been Signed on 03/03/2022 12:11 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME:	PIONEER ELEMENTARY PRESCHOOL		FACILITY NUMBER:	030319700
ADMINISTRATOR:	JESSICA VAUGHN		FACILITY TYPE:	850
ADDRESS:	24625 HIGHWAY 88		TELEPHONE:	(209) 295-6503
CITY:	PIONEER	STATE: CA	ZIP CODE:	95666
CAPACITY:	24	CENSUS: 0	DATE:	03/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Jessica Vaughn		TIME COMPLETED:	12:15 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	On 3/3/22 Licensing Program Analyst (LPA) Aruna Sridharan met with Jessica Vaughn for the purpose of an unannounced annual inspection. During the visit, the children had just left and one staff member present. All staff have all been fingerprint cleared through Amador County of Education. LPA toured the building including all activity and classroom #6 space, restrooms, food service, and outdoor play areas. LPA observed appropriate ratios, care and supervision, and capacity during the visit. The hours of operation are Monday through Friday 8:00am to 11:00am. The school year began on Aug 11, 2021 and last day is May 27, 2022. The facility has two waivers, one for shared playground usage and the other for use of shared bathrooms. Medications, disinfectants, cleaning solutions, and hazardous items were appropriately stored and inaccessible to children. First Aid was centrally located but inaccessible to children. Furniture, equipment, and play materials were in good condition. Playground equipment was free of loose and sharp parts. The areas under and around playground climbing equipment were cushioned with wood chips to absorb falls. They have access to upper playground which is used on Fridays usually. The Director stated there are no firearms or bodies of water on the property. There are 1 toilet and 1 sink. Toileting facilities were in operating, safe, and sanitary condition. Trash cans containing solid wastes had lids. Uncontaminated drinking water is readily available to children both indoors and outdoors. The Director stated that the facility provided breakfast at 8:30am through the school in the cafeteria. LPA observed a current menu posted. LPA observed Sign In/Out Sheet with signatures, times, and dates. The last documented fire drill was on 2/14/22. LPA reviewed 10 children’s files and observed that each child had their Identification/Emergency Information and the Consent for Medical Treatment form filled out and signed by their authorized representative. Report continues on 809C page......

SUPERVISOR'S NAME: Justin L Denton	TELEPHONE: (916) -92-0269
LICENSING EVALUATOR NAME: Aruna Sridharan	TELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: PIONEER ELEMENTARY PRESCHOOL	FACILITY NUMBER: 030319700
	VISIT DATE: 03/03/2022

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At least one staff member present today had current Pediatric CPR and First Aid certification (expires 10//23). All staff currently employed with the facility have proof of immunizations. LPA also reviewed documentation of qualifications including education and experience. The two staff members did not have valid mandated reporter training AB 1207. A technical violation was issued.

LPA also discussed Unusual Incident Reports (UIRs) and reporting requirements. LPA informed the Director that if any unusual incidents occur she must contact the Department within 24 hours and an UIR must be submitted with 7 day, describing the specifics to the incident. LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised the licensee of their responsibility to stay current in regards to new regulations.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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/inspection-process.

No Title 22 Deficiencies observed in the areas that were evaluated. LPA reviewed report and provided copies to the facility. A notice of site visit was given and must remain posted for30 days. Exit interview conducted and report was reviewed with the facility representative Jessica Vaughn.

SUPERVISOR'S NAME: Justin L Denton	TELEPHONE: (916) -92-0269
LICENSING EVALUATOR NAME: Aruna Sridharan	TELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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