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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 085403174
Report Date: 09/25/2019
Date Signed: 09/25/2019 02:12:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:PINE GROVE SCHOOL PRESCHOOLFACILITY NUMBER:
085403174
ADMINISTRATOR:HARTWICK, WILLIAMFACILITY TYPE:
850
ADDRESS:900 PINE GROVE ROADTELEPHONE:
(707) 464-0350
CITY:CRESCENT CITYSTATE: CAZIP CODE:
95531
CAPACITY:23CENSUS: 21DATE:
09/25/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Brooke DavisTIME COMPLETED:
02:30 PM
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An inspection was made to the facility by Licensing Program Analyst (LPA) Kiriko Lynch. The facility is a State Preschool, and is located on shared grounds with a Del Norte Unified School District elementary school site. The facility file was reviewed prior to this visit. A review of the personnel report on file on 09/24/19 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record clearances or exemptions.

The facility operates during the school year, August through June, Monday - Friday; 8 AM through 11 AM, and 12 PM through 3 PM. The facility was toured inside and outside, and the floor and yard plan submitted by the licensee were verified. The items which could pose a hazard to children such as detergents, cleaning compounds and medications were observed to be inaccessible to children. The toys, floors, desks and other equipment and surfaces are clean, and appeared safe and in good condition. There is uncontaminated drinking water available to children both indoors and outdoors via drinking fountains on the interior. The children's restrooms are in safe and sanitary condition. The facility provides breakfast and lunch and food is provided by the local school district. Garbage can had a tight fitting lid. The playground was free of hazards and play equipment and surface areas are in safe condition. There is wood chips underneath climbing structures and/or play equipment to absorb falls. There were no bodies of water observed. During today's inspection, staffing ratios and capacity were being met. Three staff were supervising 21 children. All staff present have current pediatric CPR/First Aid certifications that were observed at 1:30 p.m., and one expires on 08/15/20. Staff mandated reporter training certifications were also observed at 1:30 p.m.

See next page for continuation report
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Kiriko LynchTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2019
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: PINE GROVE SCHOOL PRESCHOOL
FACILITY NUMBER: 085403174
VISIT DATE: 09/25/2019
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Five children's files were reviewed at 2:00 p.m. Consent for medical treatment and Emergency information forms were on file. Three staff records were reviewed at 1:30 p.m., documentation of education and/or experience was present. This facility is not providing Incidental Medical Services – IMS. 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.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free American Disabilities Act 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.htm. This report was reviewed and discussed with Director. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

The facility is in substantial compliance during today’s inspection. There were no Title 22 deficiencies cited during today's visit.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Kiriko LynchTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2019
LIC809 (FAS) - (06/04)
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