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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103810134
Report Date: 11/29/2021
Date Signed: 11/29/2021 04:10:54 PM

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:WASHINGTON PRESCHOOLFACILITY NUMBER:
103810134
ADMINISTRATOR:BARKOWSKY, TIFFANYFACILITY TYPE:
850
ADDRESS:1568 WILLIAMS STTELEPHONE:
(559) 897-6989
CITY:KINGSBURGSTATE: CAZIP CODE:
93631
CAPACITY:27CENSUS: 21DATE:
11/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Site Supervisor - Tiffany BarkowskyTIME COMPLETED:
04:20 PM
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On 11/29/2021, Licensing Program Analyst (LPA) Luisa Gavoutian, conducted an unannounced Annual Inspection. LPA met with Site Supervisor Tiffany Barkowsky, who accompanied LPA on a tour of the facility, indoors and outdoors. This program is located on the Washington Elementary School campus and operates in Classroom C. This facility maintains a waiver for shared outdoor play area with Washington Preschool - Educare and special needs classes at staggered times. 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 11:15 a.m. and the afternoon session is 11:45 a.m. to 3:00 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 a tortoise in an aquarium in the classroom with a tight-fitting cover. There are no other bodies of water on the premises. There are no firearms or ammunition allowed or stored on the premises. LPA observed in the adult bathroom, which had the door closed, but unlocked, a storage container near the door that contained a razor, two spray bottles of body fragrance spray, and a travel-sized container of Vaseline. Site Supervisor removed the items from the restroom, making them inaccessible. LPA observed a hand sanitizer dispenser near the front door that contained hand sanitizer and is within children's reach. 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. LPA observed some dead flies and mosquitos in the window tracks of the classroom's windows. The facility is free of flies, insects and rodents. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements.
(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: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
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 9
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: WASHINGTON PRESCHOOL
FACILITY NUMBER: 103810134
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that a razor, toiletries, and hand sanitizer were accessible to children which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2021
Plan of Correction
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Site Supervisor removed the razor and toiletries during today's inspection. Site Supervisor will make the adult bathroom inaccessible to children or ensure no hazardous items are accessible and will remove or empty the hand sanitzer dispenser. Site Supervisor shall send proof of correction to CCL by 12/29/2021.
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two of the 21 children present were signed out at a future time and one of the 21 children present was not signed in which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2021
Plan of Correction
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Parent of one child who was not signed in arrived to the facility and signed the child in. Site Supervisor shall develop a plan to ensure that all children are signed in/out per regulation and shall submit this plan in writing to CCL by 12/29/2021.
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: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Luisa GavoutianTELEPHONE: (559) 341-4725
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2021
LIC809 (FAS) - (06/04)
Page: 5 of 9
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: WASHINGTON PRESCHOOL
FACILITY NUMBER: 103810134
VISIT DATE: 11/29/2021
NARRATIVE
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Only snacks are provided to each session, which are provided by the school’s cafeteria. All kitchen, food preparation, and storage areas are clean, free of litter/rubbish and rodents/vermin. 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, swings, and slides have cushioning material in the form of wood chips 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. The facility’s staff have fingerprint clearance through the Kingsburg Elementary Charter School District.

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. At 12:50 p.m., LPA reviewed the sign-in/out sheets and found two children had already been signed out for the pick-up time of 3:00 p.m. LPA observed that one of the 21 children present was not signed in. The child's parent returned to the facility to sign the child in. 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 children's records and found one child, who had an inhaler on site, did not have form LIC 9166 - Nebulizer Care Consent/Verification (Child Care Facilities) form completed. LPA reviewed staff files and observed the following: two of the four staff records reviewed did not have documentation of immunizations for pertussis and measles; two of the four records did not have the AB 1207 required mandated reporter training certificate; one of the four records did not have record of a health screening. (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: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC809 (FAS) - (06/04)
Page: 6 of 9
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: WASHINGTON PRESCHOOL
FACILITY NUMBER: 103810134
VISIT DATE: 11/29/2021
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Site supervisor stated that the facility has been having trouble with staffing due to the COVID-19 pandemic and the regular staff who normally teach in the classroom were temporarily out for various reasons, which is why the program’s substitutes are from the school district, which does not require the same documentation. LPA explained that all staff, including substitutes, must maintain a complete record of all forms required by the Department.

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

LPA and Site Supervisor 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, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Chapter 1, Division 12, Title 22 of the California Code of Regulations, the following deficiencies were found: (see LIC809-D). Exit interview conducted and report was reviewed with the facility representative Tiffany Barkowsky.

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



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

DATE: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
LIC809 (FAS) - (06/04)
Page: 3 of 9