103808640-9-30-2022-04-CC-JPAO-CJRSSX-20220930140840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 103808640
Report Date: 09/30/2022
Date Signed: 09/30/2022 02:08:56 PM

Document Has Been Signed on 09/30/2022 02:08 PM - 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:	OUR LADY OF PERPETUAL HELP SCHOOL		FACILITY NUMBER:	103808640
ADMINISTRATOR:	BOUCHARD, JOAN		FACILITY TYPE:	850
ADDRESS:	836 DEWITT AVENUE		TELEPHONE:	(559) 299-7504
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	26	CENSUS: 15	DATE:	09/30/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Nara Adjemian - Director		TIME COMPLETED:	02:30 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	On 9/30/22 Licensing Program Analysts (LPAs) Joseph Pacheco and Cynthia Brannon, conducted an unannounced Annual Required Inspection for the preschool license. LPAs met with Director, Nara Adjemian, and toured the facility indoors and outdoors. This facility operates on a traditional school year schedule. Days and hours of operation are Monday – Friday, 7:00am – 6:00pm. Director verified facility phone number is (559) 299-7504. There is no swimming pool or other bodies of water on the premises. 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. 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. All toilets and handwashing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. Food is either provided by a third party food service or children bring their own lunch. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors. Areas around high climbing equipment, swings and slides have cushioning material to absorb falls. The facility is free of flies, insects and rodents. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. Capacity and limitations as specified on the license are being maintained. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility or at offsite activities. The name of the child care center (CCC) director or fully-qualified teacher(s) designated to act in the director’s absence has not been reported to the Department. The person who signs the child in/out of the facility shall use their full legal signature and record the time of day. All children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than 12 children in care. LPAs reviewed a sample of children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child and medical assessment. CONTINUED ON 809-C

SUPERVISOR'S NAME: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph Pacheco	TELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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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Document Has Been Signed on 09/30/2022 02:08 PM - It Cannot Be Edited

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: OUR LADY OF PERPETUAL HELP SCHOOL	FACILITY NUMBER: 103808640
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of staff records. LPAs observed that Staff #1 and Staff #2 did not have required immunizations on file. Director did not have a influenza declination statement on file. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Director stated she would have staff get documentataion of required immunizations and she would complete an influenza declination statement and provide copies to community care licensing by 10/14/22.

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of staff records. LPAs observed that staff did not have documentation of a current AB 1207 Mandated Reporter certification on file. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	Director stated she and staff would complete the required AB 1207 Mandated Reporter training and provide copies of current certification to Community Care Licensing by 10/14/22.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph Pacheco	TELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC809 (FAS) - (06/04)

Page: 2 of 9

Document Has Been Signed on 09/30/2022 02:08 PM - It Cannot Be Edited

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: OUR LADY OF PERPETUAL HELP SCHOOL	FACILITY NUMBER: 103808640
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101212(b)

Reporting Requirements

(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review and statement from Director. During inspection Director stated that she has been the Director for nine years. A review of facility file shows no record of required paperwork provided by Licensee indicating her as Director. Community Care Licensing records indicate a different Director on file. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/14/2022
	Plan of Correction
1 2 3 4	LPAs provided Director a list of all paperwork that is required to be submitted to Community Care Licensing by Licensee to review qualifications and name her as Director. Paperwork to be submitted to Community Care Licensing by 10/14/22.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph Pacheco	TELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

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: OUR LADY OF PERPETUAL HELP SCHOOL	FACILITY NUMBER: 103808640
	VISIT DATE: 09/30/2022

NARRATIVE

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LPAs reviewed a sample of staff files which did not contain documentation of required immunizations for influenza, pertussis and measles. Staff have not completed the required AB 1207 Mandated Reporter training. Menus are posted at least one week in advance where an authorized representative can view them.
Director 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. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. Upon notification from the Department, the licensee will comply and act immediately to terminate the employment of, remove from the facility or bar from entering the facility for any person it is deemed necessary while the Department considers granting or denying an exemption.

Incidental Medical Services (IMS) are currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPAs and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program Website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D). Licensee was provided a copy of their appeal rights.
Exit interview conducted and report was reviewed with Director, Nara Adjemian. This report shall be made available to the public upon request. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph Pacheco	TELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022

LIC809 (FAS) - (06/04)

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