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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 033606958
Report Date: 10/04/2019
Date Signed: 10/04/2019 11:41:11 AM

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:JACKSON STATE PRECHOOLFACILITY NUMBER:
033606958
ADMINISTRATOR:LEONETTI, PIRETFACILITY TYPE:
850
ADDRESS:501 ARGONAUT LANETELEPHONE:
(209) 257-5338
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY:24CENSUS: 22DATE:
10/04/2019
TYPE OF VISIT:Annual/RandomANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Pamela SchaapTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Aruna Sridharan and Christopher Jackson met with Site Supervisor Pamela Schaap for an unannounced annual inspection. Today’s census was 22 preschool aged children and two staff members, who have all been fingerprint cleared through the Amador County Office of Education. LPAs toured the facility and restrooms. The Site Supervisor stated that the facility provided breakfast through the school district; LPAs observed a current menu posted on the parent board. The facility operates Monday-Friday 8:15am-11:15am.

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 rubber bark to absorb falls. Toileting facilities were in operating, safe, and sanitary condition. Drinking water is made readily available to children both indoors and outdoors. LPAs reviewed care and supervision of children and staffing ratios. Medications, disinfectants, cleaning solutions, and hazardous items were stored up high in shelf inaccessible to children. LPAs also reviewed staff's educational background /transcripts, and the facility has the appropriate staffing that meet the educational requirements.

LPAs discussed Departments inspection authority regulations with the Site Supervisor and informed her that if any changes occur regarding the Designee/Director or an employee acting in their absence must be reported to Department within 10 working days.

The director Donna Custodio also came into the facility and got updates on the handouts and forms needed.

Report continues on 809C.....

SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Aruna SridharanTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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: JACKSON STATE PRECHOOL
FACILITY NUMBER: 033606958
VISIT DATE: 10/04/2019
NARRATIVE
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LPAs also discussed Unusual Incident Reports (UIRs) and reporting requirements. LPAs 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 days, describing the specifics to the incident.

LPAs provided the Community Care Licensing website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPAs advised the licensee of their responsibility to stay current in regards to new regulations.

LPAs discussed the new Immunization Regulations SB 792, the requirement that all individuals working or volunteering at a licensed Child Care facility must have vaccinations. LPAs conducted file reviews and did not observe proof in the staff files.

LPAs discussed the Incidental Medical Services (IMS) policies with the licensee. The facility is not currently providing IMS; however, LPA discussed the IMS policy. For IMS information see the Evaluator Manual Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and Medication Regulations 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), 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: www.ada.gov/childqanda.

LPAs advised the licensee on the new regulation AB 1207- California Child Care Worker: Mandated Reporter Training. The licensee must complete the training every two years starting January 1, 2018 and retain proof of completion in the facility file. The training can be found at: mandatedreporterca.com.

In the areas that were evaluated, deficiencies were cited during the inspection. LPAs read this report to the Site Supervisor; stated that understands today’s inspection. Notice of Site Visit posted and the Site Supervisor understands it must remain posted for 30 days.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Aruna SridharanTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: JACKSON STATE PRECHOOL
FACILITY NUMBER: 033606958
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2019
Section Cited

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Personnel Requirements: At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities. This requirement
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was not met as evidenced by LPAs observed proof of First Aid Card but it was not taken through an approved vendor (EMSA).
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Type B
11/04/2019
Section Cited

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision
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(a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. LPA did not observe certificates for any staff member.
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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: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Aruna SridharanTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: JACKSON STATE PRECHOOL
FACILITY NUMBER: 033606958
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2019
Section Cited

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The day care center shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person’s personnel record that is maintained by the day care center. LPA's did not observe immunization records for two staff members.

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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: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Aruna SridharanTELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4