033605372-4-5-2023-53-CC-MMEK-CQLRC8-20230405125355

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 033605372
Report Date: 04/05/2023
Date Signed: 04/05/2023 12:54:06 PM

Document Has Been Signed on 04/05/2023 12:54 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
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME:	PLYMOUTH STATE PRESCHOOL		FACILITY NUMBER:	033605372
ADMINISTRATOR:	DONNA CUSTODIO		FACILITY TYPE:	850
ADDRESS:	18601 SHERWOOD		TELEPHONE:	(209) 283-0844
CITY:	PLYMOUTH	STATE: CA	ZIP CODE:	95669
CAPACITY:	22	CENSUS:	DATE:	04/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Site Supervisor		TIME COMPLETED:	01:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Mariya Melnichuk met with Site Supervisor Tamaran Hollingsworth for the purpose of an unannounced Annual inspection. The preschool classroom is located in portable classroom #16. LPA toured the facility inside and out. LPA observed that hazardous items (disinfectants, cleaning solutions etc.) were inaccessible to children in care. Facility days and hours of operation are Monday-Friday from 8:15 AM to 11:15 AM. Facility provides breakfast, and snack which is supplied by the school cafeteria. There were 16 children present during today's inspection with three staff. Facility runs on a 10 month program from August-June.

LPA reviewed staffing ratios, first aid supplies, furniture, equipment, fire drills and drinking water. LPA observed all required forms to be posted. LPA observed functioning carbon monoxide and smoke alarms. There are adequate toys and equipment available for children. Outdoor play area was toured, the play structure appeared to be in good repair, and there is sufficient cushioning (woodchips) under the play structure.

LPA reviewed the sign in/out log and observed that the children are properly signed in/out. LPA reviewed children’s and staff files. All staff present during today's inspection have a fingerprint clearance. Facility representative 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.

Children files were reviewed. Each child's file contained an emergency card and other required documents.

Report continues on 809-C.

SUPERVISOR'S NAME: Chayntel Hunter	TELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Mariya Melnichuk	TELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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

FACILITY NAME: PLYMOUTH STATE PRESCHOOL	FACILITY NUMBER: 033605372
	VISIT DATE: 04/05/2023

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At least one staff member present today has current Pediatric CPR and First Aid (exp. 08/2023). LPA discussed AB1207 Mandated Reporter training certificates for all staff. The Site Supervisor was reminded to renew the course every 2 years through www.mandatedreporterca.com website.

LPA checked that annual fees are current.

This facility is not currently providing Incidental Medical Services (IMS) services to children in care. IMS policy was discussed.
For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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.

In the areas that were evaluated, the deficiencies observed at the time of inspection, are cited on the LIC 809D. Exit interview conducted and report was reviewed with the site supervisor. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Chayntel Hunter	TELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Mariya Melnichuk	TELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/05/2023 12:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: PLYMOUTH STATE PRESCHOOL	FACILITY NUMBER: 033605372
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101217(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 in 3 out of 3 persons did not have mandated reporter training/ Health Report (LIC503) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/05/2023
	Plan of Correction
1 2 3 4	Staff will submit required paperwork and Site Supervisor will email proof of completed paperwork to LPA

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Chayntel Hunter	TELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Mariya Melnichuk	TELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC809 (FAS) - (06/04)

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