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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093623233
Report Date: 09/29/2021
Date Signed: 09/29/2021 02:17:11 PM

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 INFANT & TODDLER CTR (INF)FACILITY NUMBER:
093623233
ADMINISTRATOR:BROWN, KARENFACILITY TYPE:
830
ADDRESS:5723 PONY EXPRESS COURTTELEPHONE:
(530) 644-1317
CITY:POLLOCK PINESSTATE: CAZIP CODE:
95726
CAPACITY:16CENSUS: 10DATE:
09/29/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jill KimeTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Michelle Pascual met with Director Jill Kime for the purpose of an announced case management visit. The Director requests to increase the capacity from 16 to 18 infant children. The program will operate in two separate infant rooms, identified by infant room A and infant room B.

A health and safety inspection was conducted in all areas accessible to children. LPA measured 1 classroom, The total indoor capacity for the infant classroom (room A) is 246.25 which allows for 7 infants. The total space for infant room B is 386.823 which allows for 11 infants. This will accommodate the additional 2 additional children requested. The total capacity of infants is 18. LPA observed sufficient amount of furniture, toys, and play equipment in the classrooms. LPA observed a functional carbon monoxide detector in each classroom. LPA observed disinfectants and medications are inaccessible and stored appropriately. There are 3 toilets and 3 sinks in the co-ed bathroom and a separate staff restroom is available. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the front office area.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Michelle PascualTELEPHONE: (916) 704-7665
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: PINE TOP INFANT & TODDLER CTR (INF)
FACILITY NUMBER: 093623233
VISIT DATE: 09/29/2021
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OUTDOOR ACTIVITY SPACE: The infant play area is fenced that is at least four feet tall. The outdoor space is equipped with age-appropriate equipment. There is no climbing structure that is age appropriate. There are shaded areas supplied by trees.

The outdoor activity space was measured. The outdoor play area contains a total of 1413.72 square feet, which will accommodate the applicant's request for 18 infant children. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Applicant stated the teachers will bring the water pitcher and cups to provide water indoor and outdoor for the children.

The program plans to provide Incidental Medical Services and a Plan of Operation is located in the facility file. 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.htm.

LPA discussed the following: 100% supervision is required at all times, including in the bathroom; personal rights; reporting requirements; staff to children ratios, conditions of the license, staff qualifications, and maintaining buildings and grounds.

The Department received an approved fire clearance for 16 infant children on 08/29/19.

LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so Applicant can request to be added to the distribution list to receive Quarterly Updates.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Michelle PascualTELEPHONE: (916) 704-7665
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC809 (FAS) - (06/04)
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