093616214-4-9-2025-03-CC-SMAX-DFKRVP-20250409132153

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 093616214
Report Date: 04/09/2025
Date Signed: 04/09/2025 01:22:04 PM

Document Has Been Signed on 04/09/2025 01:22 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	COUNTRY KIDS DAYCARE & PRESCHOOL		FACILITY NUMBER:	093616214
ADMINISTRATOR/ DIRECTOR:	SPRINGER, ASHLEE		FACILITY TYPE:	830
ADDRESS:	610 PLEASANT VALLEY ROAD		TELEPHONE:	(530) 642-1630
CITY:	DIAMOND SPRINGS	STATE: CA	ZIP CODE:	95619
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 4	DATE:	04/09/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Adrianna Tracy		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Soleil Marx, met with Facility Representative, Adrianna Tracy, for the purpose of conducting an unannounced annual inspection. LPA observed a census of four infants being supervised by one fully qualified infant teacher. Facility hours of operation are Monday through Friday, 07:30 AM to 05:00 PM.

LPA inspected indoor activity space, restroom, food service areas, and outdoor activity space. Hazardous items were inaccessible to children. The floors appeared clean throughout the facility. Furniture and equipment were in safe, operable condition. Outdoor activity space and equipment were in good repair and free of loose or sharp parts. No high climbing structures were observed within infant yard and shaded areas are provided. Infants bring meals from home. Food preparation space was hygienic, and all food was protected against contamination. Uncontaminated drinking water was readily available to children both indoors and outdoors. Trash bins with waste have lids. LPA observed first aid supplies, a carbon monoxide detector, smoke detector, and fully charged 2A10BC fire extinguisher within the facility. LPA observed authorized representatives are using full legal signatures on the sign in and out sheet. LPA observed facility to be meeting supervision, ratio, and personal rights requirements. There are no bodies of water on the premises.

LPA observed sleep checks conducted and documented every 15 minutes for all children under two. LPA provided technical assistance for Needs and Services plans. There were no infants under 12 months enrolled in the facility at the time of inspection, therefore Infant Sleeping Plan (LIC9227) for each child under 12 months of age was not reviewed. LPA observed one crib/mat for each infant care with a tight fitted sheet. Staff stated that the bedding is changed daily. Infant diaper changing area is clean, within arm's reach of a sink, and contains a changing mat that meets requirements. Toys are of age-appropriate size, with no small parts. LPA observed labeled food and milk for infants, stored at safe temperatures. LPA observed staff documentation of feedings and diaper changes.

Natalie Dunaway	TELEPHONE: (916) 584-3508
Soleil Marx	TELEPHONE: (916) 263-5744
	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COUNTRY KIDS DAYCARE & PRESCHOOL	FACILITY NUMBER: 093616214
	VISIT DATE: 04/09/2025

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LPA reviewed facility records including child's records, personnel records, administrative records, and documents to be posted. LPA reviewed a sample of children’s files and reviewed records for present staff. Staff currently employed with the facility have: Staff currently employed with the facility have: a health screening report, immunization records, current Mandated Reporter Training, record of transcripts, and required licensing forms. Children's files obtained the required licensing forms/documentation. LPA observed a children's roster and fire drill log within the facility, with disaster drills being conducted every six months. LPA observed all required licensing documents were posted and visible to authorized representatives. LPA was unable to verify if at least one staff member present at the facility during the inspection had a current qualifying CPR course.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource.

LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

All individuals subject to criminal record review have obtained a clearance. Facility Representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1- CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES. LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

SUPERVISOR'S NAME: Natalie Dunaway	TELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil Marx	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COUNTRY KIDS DAYCARE & PRESCHOOL	FACILITY NUMBER: 093616214
	VISIT DATE: 04/09/2025

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/. This facility does not currently have any medication.

Facility representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Based on today’s inspection, one type B citation is being issued. Appeal Rights were provided.

Exit interview conducted and report was reviewed with the Facility Representative. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Natalie Dunaway	TELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil Marx	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/09/2025 01:22 PM - It Cannot Be Edited

Created By: Soleil Marx On 04/09/2025 at 12:32 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COUNTRY KIDS DAYCARE & PRESCHOOL	FACILITY NUMBER: 093616214
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216(f)

Personnel Requirements

(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having record of a staff member on-site with a current qualifying CPR course which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2025
	Plan of Correction
1 2 3 4	Facility Representative will send proof of a current pediatric cardiopulmonary resuscitation card issued either by the American Red Cross or the American Heart Association, or by a training program that has been approved by the Emergency Medical Services Authority, to LPA Marx by POC due date

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Natalie Dunaway
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (916) 584-3508

	Soleil Marx
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (916) 263-5744

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2025

LIC809 (FAS) - (06/04)

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