093623233-9-27-2019-03-CC-ESIA-BGEQ7F-20190927115503

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 093623233
Report Date: 09/27/2019
Date Signed: 09/27/2019 11:55:11 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 MONTESORRI INF		FACILITY NUMBER:	093623233
ADMINISTRATOR:	BROWN, KAREN		FACILITY TYPE:	830
ADDRESS:	5723 PONY EXPRESS COURT		TELEPHONE:	(530) 391-2604
CITY:	POLLOCK PINES	STATE: CA	ZIP CODE:	95726
CAPACITY:	16	CENSUS: 0	DATE:	09/27/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Jill Kime and Karen Brown		TIME COMPLETED:	12:15 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	Licensing Program Analysts (LPAs) Elvira Sierra and Licensing Program Manager (LPM) Bettina Engelman conducted a site visit for the purpose of a prelicensing evaluation. Licensing met with licensee representatives, Jill Kime, Applicant and Karen Brown, Director. Applicant requests an infant license for 12 infants. The facility will operate Monday-Friday from 07;30 to 05:30 PM, in classrooms A and B. Program will operate on the premises of Ridge Church. Applicant is requesting a waiver to combine infants and preschool children in the fist and last hour of the day. Parents Rights, Personal Rights, Car Seat Law, Emergency Disaster Plan, Earthquake Checklist, and facility Menu should be posted on a location that is available for public view. LPA reviewed all required records with the applicant that the facility must maintain for all of the children, staff and volunteers. LPA advised applicant that the Infants Needs and Service Plan must be updated quarterly. LPA advised applicants that anyone working in the facility must obtain a criminal record clearance through Community Care Licensing. LPA also discussed staffing qualifications and ratio/capacity regulations for an infant program with applicants. LPA discussed Departments inspection authority regulations with the applicants and informed them that if any changes occur regarding the Designee/Director or an employee acting in their absence must be reported to Department within 10 working days. LPA also discussed Unusual Incident Reports (UIRs) and reporting requirements. LPA advised applicants that if any unusual incidents occur they must contact the Department within 24 hours and an UIR must be submitted with 7 day, describing the specifics to the Department. INDOOR ACTIVITY SPACE: The classrooms are equipped with infant size furnishing and age appropriate toys that appear to be in good repair. LPAs observed there was a sink within arm’s reach of the changing table. The changing tables have raised edges that exceed the required 3 inches. There are cubbies for storing infant's personal belongings in each classroom and the facility has 8 cribs in the infant nap room, applicant stated the facility will wash the sheets daily. LPA observed a first aid kit and cleaning disinfectants stored in a cabinet with a safety latch. Applicant stated there are no poisons on the premises. Report continued on subsequent page 809-C.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2019

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 MONTESORRI INF	FACILITY NUMBER: 093623233
	VISIT DATE: 09/27/2019

NARRATIVE

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Snacks will be prepared in the kitchen, food preparation area, equipment, dishes must be sanitary and in good repair. The facility will provide AM/PM snack and the parents will provide any food for infants. Bottles will be brought from home, labeled, dated and returned daily. The facility will use a bottle warmer to warm the bottles.

LPA measured the infant classrooms. The classrooms activity area contains a total of 612.62 square feet, which will accommodate the applicant's request capacity for 16 infant children.
There is 1 toilet and 1 sink for the children and a separate private restroom for the staff. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the office and will use the staff restroom if necessary.

OUTDOOR ACTIVITY SPACE: The outdoor play area is fenced and is equipped with age-appropriate equipment. There is shaded area covered by large trees. The outdoor activity space was measured is 1424 square feet, which accommodates the requested 16 infants.

LPA advised applicant on Infant Napping Regulations, Safe Sleep practices and SIDS and the requirement to have direct 100% supervision for sleeping infants.

The applicant will use the office to isolate sick infants and the infants will be accompanied by a qualified staff. LPA advised applicants on medication requirements and they are aware that all medications must be centrally stored. The facility will have a locked box in the staff bathroom for medications.
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.

Report continued on subsequent page 809-C

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 MONTESORRI INF	FACILITY NUMBER: 093623233
	VISIT DATE: 09/27/2019

NARRATIVE

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Fire clearance was granted for a capacity of 16 children on 08/29/19.

CONDITIONS REQUIRING CORRECTION PRIOR TO ISSUING A LICENSE:

-Playground is free of miscellaneous debris or hazards such as tree branches, cans,
bottles, glass, etc.
-Fix the broken wooden board in the infant play yard.
-Child passenger restraint system poster, Menus for one week in advance, Parents’Rights Form, Personal Rights Form (LIC 613A) Emergency Disaster Plan (LIC 610) & Earthquake Preparedness Checklist (LIC9148) must be posted.
-An approved partition for the crib area.
-Mandated Reporter for applicant
-LPM's final file review.

This report was reviewed and a copy was provided to Applicant.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2019

LIC809 (FAS) - (06/04)

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