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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053604815
Report Date: 09/10/2019
Date Signed: 09/10/2019 01:30:08 PM

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:HAZEL FISCHER EXTENDED DAY PROGRAMFACILITY NUMBER:
053604815
ADMINISTRATOR:AMY STURDIVANTFACILITY TYPE:
840
ADDRESS:1605 BLAGEN ROADTELEPHONE:
(209) 795-1033
CITY:WHITE PINESSTATE: CAZIP CODE:
95223
CAPACITY:36CENSUS: 0DATE:
09/10/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Terry FarmerTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Justin Denton met with Site Supervisor Terry Farmer for a random annual inspection. This facility is located on the Hazel Fischer Elementary campus. Present today was one staff.

LPA toured the facility including all activity/classroom areas, the isolation area, food service area, and outdoor play areas. LPA reviewed care and supervision of children, staffing ratios, health related services, furniture, equipment, drinking water and food service provisions. The facility has an outside play ground area and a bathroom on-site.

LPA reviewed the children's Identification and Emergency Information. LPA reviewed personnel's education and immunization requirements. Criminal record clearances of all staff currently employed with the center are maintained by the Calaveras County Office of Education. At least one staff member present today has current EMSA approved Pediatric/Child CPR and First Aid.

This facility does not provide 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 order forms please visit our website at www.ccld.ca.gov

No deficiencies observed in the areas inspected during today's visit.

Licensing report was reviewed and discussed with the site supervisor. Copy of Appeal Rights left with the facility.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2019
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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