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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093614550
Report Date: 11/26/2019
Date Signed: 11/26/2019 09:44:05 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:PINE TOP MONTESSORI SCHOOLFACILITY NUMBER:
093614550
ADMINISTRATOR:KIME, JILLFACILITY TYPE:
850
ADDRESS:6526 PONY EXPRESS TRAILTELEPHONE:
(530) 903-3106
CITY:POLLOCK PINESSTATE: CAZIP CODE:
95726
CAPACITY:30CENSUS: 11DATE:
11/26/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jill KimeTIME COMPLETED:
09:30 PM
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Licensing Program Analysts (LPAs) Elvira Sierra and Gagandeep Singh met with Director, Jill Kime for the purpose of an unannounced annual random inspection. Census included 11 preschool children supervised by 3 staff members. Facility operates from M-F, during school calendar: 07:30 AM – 05:30 PM. This is a combination center with a toddler component on site. Director stated that she will submit an application to remove toddler component..

LPAs toured all activity and classroom spaces, restrooms, food service, and outdoor play areas. Director stated there are no poisons on the premises. Toxic and hazardous items are inaccessible to children. Furniture and equipment are in good condition. Playground equipment and surfaces are free of loose or sharp parts. The areas around or under climbing equipment are cushioned with tank bark to absorb the fall. Toileting facilities are in safe, sanitary and operating condition. The floors appeared clean throughout the facility. The food preparation space is clean and free of litter. Storage containers with solid waste have tight-fitting covers. Program provides meals. Menus were posted and drinking water was readily available to children both indoors and outdoors. There are no firearms or bodies of water on the premises. LPAs observed a functional carbon monoxide detector. LPAs reviewed the Department's inspection authority and discussed wit Director any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within ten working days. LPAs reminded Director that 100% supervision is required at all times, including in the bathroom.

Staff and children's records were reviewed. All staff currently employed with the facility have a criminal record clearance, health screening report, and documentation of the educational background, training, and/or experience. At least one staff member present today has current Pediatric CPR and First Aid certificate. LPAs observed child’s admission agreement on children’s files. Full legal signatures and time was observed in sign in/out sheets. Director was reminded before working or volunteering in a licensed child care facility, all individuals subject to a criminal record review have a clearance or exemption and have been associated to the facility,


------------------Report continued on subsequent page 809C...
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2019
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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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: PINE TOP MONTESSORI SCHOOL
FACILITY NUMBER: 093614550
VISIT DATE: 11/26/2019
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Facility is not providing Incidental Medical services. 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, a 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.

LPA reviewed AB 1207- Mandated Reporter Training. Staff must complete the training every two years starting January 1, 2018 and retain proof of completion in the facility file. The training can be found at: mandatedreporterca.com. LPA observed all staff have completed the training.

Safe Sleep in Child Care, Effects of Lead exposure and Quarterly Update Summer 2019 publications were provided to Director.

Director was updated on new immunization requirements from the Department of Public Health(CDHP) that will become effective July 1, 2019. Additional information and resources can be found on the https://www.shotsforschool.org website.

LPA verified the annual fees are current.

This facility evaluation report was reviewed and discussed with Director. A Notice of Site Visit was provided and should remain posted for a period of 30 days for parental review. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so Director can request to be added to the distribution list to receive Quarterly Updates. Director was encouraged to the visit the department's website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining child care centers. In the areas that were evaluated, no deficiencies were observed at the time of the visit.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2