<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093624012
Report Date: 08/06/2021
Date Signed: 08/06/2021 12:25:41 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:NORTHSIDE PRESCHOOLFACILITY NUMBER:
093624012
ADMINISTRATOR:PETTIT, JENNYFACILITY TYPE:
850
ADDRESS:860 CAVE VALLEY ROADTELEPHONE:
(530) 295-2330
CITY:COOLSTATE: CAZIP CODE:
95614
CAPACITY:24CENSUS: 0DATE:
08/06/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Colleen Braunbeck and Jenny PettitTIME COMPLETED:
12:40 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
Application Specialist (AS) Mai Lor met with Applicant Jennifer Pettit and Program Coordinator Colleen Braunbeck for the purpose of an announced pre-licensing inspection. Applicant requests a preschool license to serve 24 preschool children from age two to entry into Kindergarten. The program will operate Monday through Friday from 8:30 AM to 12:00 PM. The fire clearance was granted on 8/4/21.

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. AS provided and discussed LIC311A and the forms that must be in each child's and each staff member's file.

INDOOR ACTIVITY SPACE:
There is one preschool classroom. AS observed a sufficient number of tables, chairs, cubbies, and napping cots for 24 preschool children. AS and LPM observed a variety of age-appropriate toys and equipment. There is a first aid kit in in the director's office. ;Medications will be stored in a locked box in the director's office. Applicant stated cleaning disinfectant will be stored out of reach of children. Applicant stated there are no poisons or firearms on the premises. Applicant stated water jug will be used for both indoor and outdoor. AS observed a functional carbon monoxide detector in the classroom. AS observed paper sign-in/sign-out system.

AS measured the classroom. The total classroom space contains a total of 909.293 square feet, which accommodates Applicant's request for 24 preschool children. There are two toilets and three sinks for the children, and a separate private restroom for the staff located in the school office. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the office area and will use one in the children's restroom, if necessary.

Report continues on 809-C.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 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: NORTHSIDE PRESCHOOL
FACILITY NUMBER: 093624012
VISIT DATE: 08/06/2021
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
26
27
28
29
30
31
32
OUTDOOR ACTIVITY SPACE:
There is one outdoor area on the property for preschool children. The outdoor play area is fenced with chained linked fence that is four feet tall. The play structure includes a safety label, which designates use for children 2 to 5 years old. AS observed artificial grass under the play structure that provides enough cushion to absorb a fall. There are no bodies of water on the premises. There are shaded areas supplied by sun sail shade and overhangs.

AS measured the outdoor activity space. The outdoor play area contains a total of 2999.535 square feet, which accommodates Applicant's request for 24 preschool children. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

The facility's Plan of Operation is located in the preschool 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.

AS discussed the following: 100% supervision is required at all times, including in the bathroom; personal rights; inspection authority; reporting requirements; staff to children ratios and capacity; staff qualifications; and maintaining buildings and grounds. AS 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.

Report continues on 809-C.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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: NORTHSIDE PRESCHOOL
FACILITY NUMBER: 093624012
VISIT DATE: 08/06/2021
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
26
27
28
29
30
31
32
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. Pending manager's final approval

2. Verification of Director's lead training

Exit interview conducted.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai LorTELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3