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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103808769
Report Date: 05/27/2025
Date Signed: 05/27/2025 03:30:09 PM

Document Has Been Signed on 05/27/2025 03:30 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
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:TEAGUE ELEMENTARYFACILITY NUMBER:
103808769
ADMINISTRATOR/
DIRECTOR:		LEE, YINGFACILITY TYPE:
850
ADDRESS:4725 N. POLKTELEPHONE:
(559) 276-5260
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 16TOTAL ENROLLED CHILDREN: 16CENSUS: 15DATE:
05/27/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Annette McGuire, TeacherTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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On 05/27/2025, Licensing Program Analyst (LPA) Vang conducted an unannounced case management inspection. LPA toured the facility and a census was taken. LPA explained to Staff #1 (S1) the purpose of today’s inspection was to follow up with an unusual incident reported to Community Care Licensing (CCL)-Fresno Office on 05/08/2025 via email. Per the Unusual Incident Injury Report (LIC 624), Child #1 (C1) complained of pain, and it was later determined by Valley Children Hospital’s physician that C1 sustained a fracture on his right arm.

On 05/08/2025, LPA Vang received LIC 624 via email stated that on 04/28/2025 at 10:45 a.m., C1 was found by S1 under the play structure, and C1 complained of arm pain. Due to C1 limited English language, C1 informed S1 that he was running and fell, but did not provide further details. S1 then applied an ice pack on C1’s arm and observed that there was no open wound or bruises on C1’s arm. At the end of class session, C1’s authorized representative (AR) was informed of the incident that C1 complained of pain in C1’s arm.

Based on interviews, C1 did not return to facility the following day, 04/29/2025 or 04/30/2025, therefore, S1 contacted C1’s AR via email. On 04/30/2025, C1’s AR informed S1 that C1 was seen by Valley Children's Hospital physician and confirmed to had a fracture on C1's right arm; therefore, C1 was out on 04/29/2025, 04/30/2025. C1 was out of class from 04/29/2025 to 05/02/2025 and returned to the facility on 05/05/2025.

The above incident of C1 sustained an injury and was seen by a medical doctor was not reported to CCL-Fresno Office within the next working day of the Department’s normal business day although staff member became aware of C1's right arm fracture on 04/30/2025. The incident was reported to CCL-Fresno Office on 05/08/2025.

(Continued on LIC809-C).

Kari McWilliamsTELEPHONE: (559) 650-7854
Ka VangTELEPHONE: (559) 410-0327
DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/27/2025 03:30 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
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: TEAGUE ELEMENTARY
FACILITY NUMBER: 103808769

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2025
Section Cited
CCR
101212(d)(1)(B)

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(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours…(B) Any injury to any child that requires medical treatment.
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S1 stated that she will follow-up with the district site supervisor to submit a plan of correction (POC) to the Department indicating that all staff understand licensing regulation of reporting requirement. Licensee is to submit POC to the Department including sign in sheets and details of the meeting. The POC is to be submitted to the Department by 06/10/2025.
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This requirement was not met as evidenced by the unusual incident report (LIC 624). On 04/28/2025, staff #1 (S1) observed child #1 (C1) complained of pain in C1’s arm. On 04/30/2025, S1 was informed by C1’s authorized representative that C1 was seen by a physician and confirmed to have an injury to C1’s right arm. Facility representative failed to report the unusual incident to CCL-Fresno within the next working day of the Department’s normal business day. This poses a potential risk to health, safety, or personal rights of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kari McWilliamsTELEPHONE: (559) 650-7854
Ka VangTELEPHONE: (559) 410-0327

DATE: 05/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2025

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
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: TEAGUE ELEMENTARY
FACILITY NUMBER: 103808769
VISIT DATE: 05/27/2025
NARRATIVE
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Per Title 22, Division 12, Chapter 1 of the California Code of Regulations, the following deficiency is being cited during today’s inspection. (See LIC809-D page).

Exit interview conducted and report was reviewed with S1. S1 was provided with appeal rights. This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Kari McWilliamsTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Ka VangTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2025
LIC809 (FAS) - (06/04)
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