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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 033616307
Report Date: 09/18/2019
Date Signed: 09/18/2019 11:01:57 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:AMADOR TUOLUMNE COMMUNITY ACTION AGENCYFACILITY NUMBER:
033616307
ADMINISTRATOR:FERNER, KATIEFACILITY TYPE:
830
ADDRESS:101 SHOPPING DRIVETELEPHONE:
(209) 223-1485
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY:12CENSUS: 12DATE:
09/18/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Katie FernerTIME COMPLETED:
11:20 AM
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Licensing Program Analysts (LPA) Aruna Sridharan and Christopher Bello met with Head Teacher Katie Ferner for the purpose of an annual random inspection. LPAs toured the building including all activity and classroom spaces, restrooms, food service, and outdoor play areas. LPAs observed appropriate ratios, care and supervision, and capacity during the visit. The facility operates Monday-Friday 8:30am-02:30pm.

Medications, disinfectants, cleaning solutions, and hazardous items were appropriately stored and 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 to absorb falls. Toileting facilities were in operating, safe, and sanitary condition. All food was protected against contamination. Trash cans containing solid wastes had lids. Uncontaminated drinking water was readily available to children both indoors and outdoors. Menu was posted in a visible area. LPAs observed Sign In/Out Sheet with signatures, times, and dates.

This facility provides Incidental Medical Services – IMS. LPAs 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

Report continues on 809C.......

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

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
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 2
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: AMADOR TUOLUMNE COMMUNITY ACTION AGENCY
FACILITY NUMBER: 033616307
VISIT DATE: 09/18/2019
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Children’s records were reviewed and included contact information of responsible parties and admission agreements. At least one staff member present today had current Pediatric CPR and First Aid certification (expires 07/20). All staff currently employed with the facility have criminal record clearances and documentation of qualifications including education and experience. LPAs discussed the Departmental inspection authority, and also informed the Licensee that any changes regarding the Center Director or their Designee must be reported to Department within 10 working days.

An Exit Interview was conducted. A Notice of Site Visit was provided. Licensee was encouraged to the visit the Departmental website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, provider information notices, regulations and legislation pertaining child care centers.

No Title 22 Deficiencies observed in the areas that were evaluated. LPA reviewed report and provided copies to the facility. An exit interview was conducted. LPA observed the Notice of Site Visit posted and the director 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: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2