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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 100407512
Report Date: 02/16/2022
Date Signed: 02/16/2022 11:39:23 AM


Document Has Been Signed on 02/16/2022 11:39 AM - It Cannot Be Edited

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:TARA LOGANFACILITY TYPE:
850
ADDRESS:1880 FOWLERTELEPHONE:
(559) 327-9186
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:60CENSUS: 12DATE:
02/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Teacher Director - Christina ServinTIME COMPLETED:
11:50 AM
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On 02/16/2022, Licensing Program Analyst (LPA) Luisa Gavoutian, conducted an unannounced Annual Inspection. LPA met with Teacher Director, Christina Servin, who accompanied LPA on a tour of the facility, indoors and outdoors. This facility is located on the Jefferson Elementary School Campus and operates in rooms P1, P3, and P4. This facility maintains a waiver for shared bathrooms in the IMC room. This is an AM/PM half day program which operates on a traditional school year schedule. The morning session is 8:00 a.m. to 11:00 a.m. and the afternoon session is 11:45 a.m. to 2:45 p.m., Monday through Friday.

All children are under supervision, including visual supervision, of a teacher at all times. There is a ratio of one teacher supervising no more than 12 children in attendance. There is no swimming pool or other bodies of water on the premises. There is a fish tank in room P4 that is equipped with a tight-fitting cover. There are no firearms or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions, medication, and other hazardous items are made inaccessible. No poisons were observed during the inspection.

Furniture and equipment are in good condition, free of sharp, loose, or pointed parts. All toilets and handwashing facilities are in safe and sanitary operating condition. All floors are clean and safe. The facility is free of flies, insects and rodents. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements.

Meals are provided by the school cafeteria and children have the option of bringing their own food from home. All kitchen, food preparation, and storage areas are clean, free of litter/rubbish and rodents/vermin. (Continued on LIC 809-C)
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Luisa GavoutianTELEPHONE: (559) 341-4725
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: JEFFERSON STATE PRESCHOOL
FACILITY NUMBER: 100407512
VISIT DATE: 02/16/2022
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All food is protected against contamination and any contaminated food is discarded immediately. Solid waste storage containers have tight-fitting covers and are in good repair. Uncontaminated drinking water is available both indoors and outdoors. Menus are posted at least one week in advance where an authorized representative can view them.

Playground equipment is in safe condition, free of sharp, loose, or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. Areas around high climbing equipment and slides have cushioning material in the form of poured rubber to absorb falls.

Facility Representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. All staff receive fingerprint clearance through Clovis Unified School District prior to initial presence at the facility.

Capacity and limitations as specified on the license are being maintained. At least one person trained in Pediatric CPR and First Aid is present when children are at the facility or at offsite activities. The person who signs the child in/out of the facility uses their full legal signature and records the time of day. LPA reviewed a sample of children’s files and observed files were complete with contact information for authorized representatives or others who can assume responsibility if the authorized representative cannot be reached. LPA observed that all children’s files contained a medical assessment. LPA reviewed staff files and observed files were complete with health screening, immunization records for influenza, pertussis, and measles, and current documentation of completed mandated reporter training.

This facility provides Incidental Medical Services- IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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 (Continued on LIC 809-C)
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Luisa GavoutianTELEPHONE: (559) 341-4725
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: JEFFERSON STATE PRESCHOOL
FACILITY NUMBER: 100407512
VISIT DATE: 02/16/2022
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LPA and Facility Representative discussed the Community Care Licensing (CCL) website (www.ccld.ca.gov) which provides access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Lead Poisoning Facts, Forms and Regulations.

Per Chapter 1, Division 12, Title 22 of the California Code of Regulations no deficiencies were observed today. Exit interview conducted and report was reviewed with the facility representative Christina Servin.

A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Luisa GavoutianTELEPHONE: (559) 341-4725
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC809 (FAS) - (06/04)
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