093623955-6-17-2021-03-CC-JHOA-C43P3M-20210617105745

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 093623955
Report Date: 06/17/2021
Date Signed: 06/17/2021 10:57:51 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:	CAMERON PARK MONTESSORI SCHOOL INC		FACILITY NUMBER:	093623955
ADMINISTRATOR:	ANNE BEEMAN, KIMBERLY		FACILITY TYPE:	830
ADDRESS:	4140 MOTHERLODE DRIVE STE 104		TELEPHONE:	(530) 677-1776
CITY:	SHINGLE SPRINGS	STATE: CA	ZIP CODE:	95682
CAPACITY:	12	CENSUS: 0	DATE:	06/17/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Kimberly Anne Beeman		TIME COMPLETED:	11:20 AM

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	On Thursday, 06/17/21 at 8:30am, Licensing Program Analyst (LPA) Jan Hoshida met with Applicant Kimberly Anne Beeman for the purpose of an announced pre-licensing inspection. Applicant requests an infant license to serve 12 infant children from birth to two years of age. The program will operate Monday through Friday from 7:00am 5:00pm. The fire clearance was granted on 6/11/21 pending pictures of exit/lighting and extinguishers. Applicant acknowledges that the following documents must be posted at all times: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, Effects of Lead Exposure, car seat poster, menus, and daily schedule. LPA provided and discussed LIC311A and the forms that must be in each child's and each staff member's file. Applicant stated the Needs and Services plans will be kept in the classrooms. The families will be providing breakfast, lunch, snacks, formula, breast milk, and baby food for their children. INDOOR ACTIVITY SPACE: There are three infant classrooms and one napping room. LPA observed a sufficient number of chairs for 12 infants. LPA observed four cribs and nine napping mats. Applicant acknowledges there will be a maximum of four infants under 12 months old, due to available cribs. LPA observed a variety of age-appropriate toys and equipment. There is a first aid kit in a location accessible to staff but inaccessible to children. Medications will be stored in the front room in a locked box. LPA observed cleaning disinfectants are appropriately stored and inaccessible to children. Applicant stated there are no poisons or firearms on the premises. Applicant stated that children will bring their own sippy cups or bottles for water and LPA observed water jugs to refill them when needed. LPA observed a functional carbon monoxide detector in the hallway. LPA observed a sign-in/sign-out system. *REPORT CONTINUED ON NEXT PAGE*

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Jan Hoshida	TELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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: CAMERON PARK MONTESSORI SCHOOL INC	FACILITY NUMBER: 093623955
	VISIT DATE: 06/17/2021

NARRATIVE

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LPA did not observe a sufficient number of tables or cubbies for 12 infants. Applicant stated that the table has been ordered and she will purchase cubbies to put in the shelving unit.

LPA measured the three classrooms. The total classroom space contains a total of 719.80
square feet, which will accommodate Applicant's request for 12 infant children. There is one toilet, two potty chairs, and one sink for the children, and a separate private restroom for the staff within the building. LPA observed a changing table within arm's reach of a sink with a changing pad that is at least one inch thick with raised sides that are at least three inches tall. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the back classroom and will use the staff restroom, if necessary.

LPA provided Applicant with the safe sleep PIN 20-24-CCP and a blank Infant Individual Sleeping Plan (LIC 9227) form for their records.

LPA discussed current COVID child care guidelines with Applicant.

OUTDOOR ACTIVITY SPACE:
There is one outdoor area on the property for infant children. The outdoor play area is fenced with a chain-linked fence that is at least four feet tall and separates the preschool and infant yards. LPA observed a variety of age-appropriate outdoor toys and equipment. There is no play structure within the infant yard. LPA observed an area that provides cushioning material in a portion of the outdoor play area. There are no bodies of water on the premises. There are shaded areas supplied by trees and an overhanging. Applicant stated that they will bring out children’s water bottles and water jugs for refilling while outside.

LPA measured the outdoor activity space. The outdoor play area contains a total of 758.89 square feet, which will accommodate up to 10 children. Applicant has submitted a waiver request for the outdoor activity space and understands that they can only have up to 10 children at a time in the outdoor activity space. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

The facility's Incidental Medical Services (IMS) Plan of Operation is located in the preschool file. 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.

REPORT CONTINUED ON NEXT PAGE

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Jan Hoshida	TELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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: CAMERON PARK MONTESSORI SCHOOL INC	FACILITY NUMBER: 093623955
	VISIT DATE: 06/17/2021

NARRATIVE

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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, personal rights, inspection authority, reporting requirements, staff to children ratios and capacity, staff qualifications, and maintaining buildings and grounds. LPA discussed with Applicant any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

This facility evaluation report was reviewed and discussed with Applicant. Applicant was encouraged to the visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to child care centers.

The following items are required before a license will be issued:

1. Licensing Program Manager’s final file review.

2. Final fire inspection approval.

3. Proof of sufficient number of tables and cubbies within the facility.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Jan Hoshida	TELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC809 (FAS) - (06/04)

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