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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100407512
Report Date: 09/18/2019
Date Signed: 09/18/2019 10:30:03 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:JEFFERSON STATE PRESCHOOLFACILITY NUMBER:
100407512
ADMINISTRATOR:KIYUNA, CHARLENEFACILITY TYPE:
850
ADDRESS:1880 FOWLERTELEPHONE:
(559) 327-9186
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:60CENSUS: 19DATE:
09/18/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Christina ServinTIME COMPLETED:
10:45 AM
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Licensing Program Analysts (LPAs) Candis Rodriguez and Kathy Pacheco conducted a case management inspection regarding an incident that occurred on 09/12/2019, where a child had a medical emergency due to skin contact with a dairy product. LPAs met with Director Christina Servin and explained the reason of the inspection. A tour of the center was conducted, and a census was taken. LPAs observed a total of 19 children in the preschool classroom.
Director stated the incident occurred at approximately 10:25 AM on 09/12/2019. Director stated Child #1 was known to have a peanut allergy and a dairy allergy, but his health history report did not specify they can have a reaction to skin contact with dairy products. Director stated 911 and parent were called immediately. Child #1 received immediate first aid, and was cleared by the Emergency Medical Technician, resulting in parent taking Child #1 home for the day. Director stated all teachers and staff have been educated on Child #1’s needs and extra precautions are being taken.
LPAs reviewed Child #1’s file. Child #1’s health history report on file with the school did not reflect a severe dairy allergy, only a general allergy to dairy and peanuts. The health history report did not indicate a serve allergy to dairy by skin contact. Director stated she is waiting for Child #1’s parents to provide an updated form from Child #1’s physician.

Upon review of facility files, it was determined at the time of the incident, there were 4 staff and 18 children present.

BASED UPON INFORMATION THAT WAS OBTAINED FROM WITNESSES AND FACILITY RECORDS, IT IS DETERMINED THAT THERE WERE NO VIOLATIONS OF COMMUNITY CARE LICENSING REGULATIONS. NO FURTHER ACTION IS REQUIRED AT THIS TIME.

Site Visit Notice posted on the parent board. Exit interview was conducted.
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Candis RodriguezTELEPHONE: (559) 341-4117
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2019
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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