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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405648
Report Date: 04/18/2023
Date Signed: 04/18/2023 03:22:00 PM


Document Has Been Signed on 04/18/2023 03:22 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:WHITE PONY, THEFACILITY NUMBER:
073405648
ADMINISTRATOR:SUSAN KOHLFACILITY TYPE:
850
ADDRESS:999 LELAND DR.TELEPHONE:
(925) 938-9958
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:141CENSUS: 85DATE:
04/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Susan KohlTIME COMPLETED:
03:45 PM
NARRATIVE
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On 04/18/2023 at 12:00PM Licensing Program Analyst (LPA), A. Curry conducted an unannounced random inspection. LPA met with designated facility Director, Susan Kohl. This is a preschool age program licensed for 141 children which operates Monday – Friday from 8:00 AM – 5:30 PM. Per the Director there are 131 children enrolled.

LPA A. Curry began facility tour with Director. All areas identified on the facility sketch were inspected. LPA observed 85 children with 19 staff. Teacher-child ratios were observed to be in accordance with Title 22 regulations. The Licensee is within the conditions, limitations, and capacity specified on the license. Staff names were recorded. All children were observed to be under visual supervision of a teacher at all times.

LPA observed the facility to be clean, safe, sanitary and in good repair. Furniture and equipment was inspected for good repair, free of sharp, loose, or pointed parts. All indoor classrooms were inspected to ensure that the floors have a surface that is safe and clean. All toilets and hand washing facilities are in safe and sanitary operating conditions. All materials and surfaces accessible to children are toxic free. At this time, the office is used as an isolation area. Parents are contacted immediately when children are determined to be ill and staff are ensuring that children with obvious symptoms of illness are not being accepted.

Food storage area is clean, free of litter, rubbish, and rodents/vermin. All food is protected from contamination. There is drinking water available in all indoor classrooms and individual drinking containers are taken outdoors. All storage containers for solid waste, including moveable bins, have tight fitting covers on and are in good repair. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are stored in an area inaccessible to children. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. The licensee takes measures to keep the facility free of flies, other insects and rodents.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: WHITE PONY, THE
FACILITY NUMBER: 073405648
VISIT DATE: 04/18/2023
NARRATIVE
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Outdoor play equipment was observed to be in good condition, free of sharp, loose or pointed parts. Outdoor activity space surface is maintained in a safe condition and is free of hazards. Areas around and/or under climbing equipment have cushioning material to absorb a fall. LPA did not observe any bodies of water during this visit. Director states there are no weapons or firearms on the premises.

Sign in and out sheets are electronic and were reviewed. Staff Records were reviewed to ensure that a health screening report and immunization records is on file. Multiple staff did not have proof of immunity against measles in file (Please see 809D). Director indicated they were following an older law that states employees were exempt from providing proof of immunity against measles if employee was born before 1957. Director has contacted all employees and advised them to obtain proof of immunity against measles. Children’s Records were reviewed to ensure that Identification and Emergency form and a medical assessment are on file. 2 staff members did not have criminal Record Clearance (Please see809D). One staff member completed the fingerprints during todays visit. The facility is aware that both employees are not allowed to work until they receive criminal record clearance. The director indicated she was having trouble accessing Guardian. The CPR/First Aid and health preventative practices documentation was reviewed.



Incidental Medical Services (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

Licensee 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.

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 04/18/2023 03:22 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: WHITE PONY, THE
FACILITY NUMBER: 073405648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by ensuring all staff had proof of immunity against measles, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2023
Plan of Correction
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By 05/18/2023 the facility will provide proof of immunity against measles for 7 staff members listed on the LIC859.
Type B
Section Cited
CCR
101170(d)
Criminal Record Clearance
(d) All individuals subject to criminal record review shall, be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above ensuring all staff have a criminal record clearance and associated to the facility, which poses/posed a potential health, safety or personal rights risk to persons in care. During today's visit 1 staff member completed fingerprints and facility is working with Guardian to associate the other staff member.
POC Due Date: 05/02/2023
Plan of Correction
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By 05/02/2023 the facility will have staff complete fingerprint and/or associated to the facility. Once associated the director will inform LPA.
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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: WHITE PONY, THE
FACILITY NUMBER: 073405648
VISIT DATE: 04/18/2023
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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/process.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted, appeal rights were given, and report was reviewed with director Susan Kohl.

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Ashley CurryTELEPHONE: 510-566-1562
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC809 (FAS) - (06/04)
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