073408290-8-31-2021-02-CC-MSUN-C6EU6W-20210831151903

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073408290
Report Date: 08/31/2021
Date Signed: 08/31/2021 03:19:10 PM

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:	ST. JOHN'S PRESCHOOL		FACILITY NUMBER:	073408290
ADMINISTRATOR:	SHONECE BARNEY		FACILITY TYPE:	850
ADDRESS:	5555 CLAYTON ROAD		TELEPHONE:	(925) 672-8855
CITY:	CLAYTON	STATE: CA	ZIP CODE:	94517
CAPACITY:	58	CENSUS: 12	DATE:	08/31/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Tonya Dean		TIME COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 8/31/21 at 1:45 PM Licensing Program Analysts (LPAs) Michelle Sutton and Monica Mathur conducted an unannounced Annual inspection at St. John's Preschool. LPAs met with Director, Tonya Dean and explained the purpose of today's inspection. LPAs were granted inspection authority to enter the facility. Facility's operating days and hours are Monday to Friday 6:15 AM to 6:00 PM. The physical plant was inspected. LPAs toured the premises with the Director. Indoor space: Facility operates in 2 Rooms - Seahorse and Sea turtles Seahorse Room: 1 teacher with 6 children Sea turtles Room: 1 teacher with 6 children Facility was observed to be in compliance with teacher to children ratio requirement during LPAs' inspection. The classrooms, restrooms, food storage areas and spaces accessible to children were inspected. Disinfectants, cleaning solutions, poisons and other items that are dangerous to the health and safety of children were stored in places inaccessible to children. Storage areas for poisons were locked and medications were kept in a safe place inaccessible to children. Furniture and equipment were age appropriate and in good condition, free of sharp, loose, or pointed parts. Restrooms for children were observed, all toilets, hand washing area, safe and sanitary operating condition. All floors were clean and safe. Foods and beverages were stored safely. Food storage area were clean, free of litter, rubbish, and free of rodents and other vermin. Trash cans for solid waste had tight-fitting covers on and were in good repair. LPA observed Fire extinguisher, Smoke and Carbon Monoxide Detectors. All materials and surfaces accessible to children appeared to be toxic free. Menus were observed to be posted at least 1 week in advance in a place visible by the child’s authorized representative, dated and kept on file for 30 days and made available upon request.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle Sutton	TELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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: ST. JOHN'S PRESCHOOL	FACILITY NUMBER: 073408290
	VISIT DATE: 08/31/2021

NARRATIVE

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Outdoor Space: Outdoor playground was inspected and observed to be fenced and safe. The play equipment was maintained in good condition and free of hazards. Surface of the outdoor activity space was in safe condition and free of hazards. There were no bodies of water observed. Drinking water is readily available to children during indoor and outdoor activities.

File Review: Children sign in and out procedures and logs were reviewed. All children were signed in by their authorized representative with full legal signatures. A sample of six (6) Children's files and three (3) Staff files was taken for review.
Child files contained LIC700 Information and Emergency Forms and Medical Assessments – Physician’s Report LIC701, Child’s Preadmission Health History - Parent Report LIC702 and immunization record.
Staff files LPA reminded director that each staff file must contain LIC501 Personnel Record. Staff files contained LIC503, immunizations and current Mandated Reporter Training. There was at least one staff present with current certification in Pediatric CPR and First Aid at the facility during inspection. Children's Roster and Personnel Report was reviewed, and a copy obtained.

Director was reminded about ensuring that each child is accorded their personal rights. LPA informed Director that the Department shall notify the licensee to immediately terminate the employment of or to remove/bar any person with specified convictions or for other reasons. The licensee shall comply with the notice.

LPA reminded Director of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day with a maximum of $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day with a maximum of $3000.00 per person.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle Sutton	TELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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: ST. JOHN'S PRESCHOOL	FACILITY NUMBER: 073408290
	VISIT DATE: 08/31/2021

NARRATIVE

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LPA reminded Director about violations that would result in an immediate assessment of civil penalty in the amount of $500. Director is encouraged to visit the Department’s website at www.cdss.ca.gov to access resources for Providers, Title 22 Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.
Director receives Provider Information Notices (PINs)

In the areas that were evaluated, no regulatory violations were observed. Exit Interview was conducted with Director, where this report was reviewed and discussed. Report was signed by the Director confirming receipt of documents.

A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS AND APPEAL RIGHTS GIVEN.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Michelle Sutton	TELEPHONE: (510) 725-7004
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC809 (FAS) - (06/04)

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