203801343-8-26-2021-04-CC-ASLR-C69QBD-20210826120121

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 203801343
Report Date: 08/26/2021
Date Signed: 08/26/2021 12:01:25 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:	POMONA MIGRANT HEAD START		FACILITY NUMBER:	203801343
ADMINISTRATOR:	LUGO, MARIA DEL LOURDES		FACILITY TYPE:	850
ADDRESS:	11777 WOODWARD WAY		TELEPHONE:	(559) 661-0269
CITY:	MADERA	STATE: CA	ZIP CODE:	93637
CAPACITY:	38	CENSUS: 7	DATE:	08/26/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Lourdes Lugo		TIME COMPLETED:	12:00 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 08/26/21, Licensing Program Analyst (LPA) Angelica Slaughter conducted an unannounced annual inspection at the facility. LPA met with Director, Lourdes Lugo, and toured the facility indoors and outdoors. There were no bodies of water, firearms and/or ammunition on the premises. No poisons were observed during the inspection. Furniture and equipment were in good condition, free of sharp, loose or pointed parts. Playground equipment was in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space was maintained in a safe condition and was free of hazards. Areas around high climbing equipment, swings and slides have wood chip cushioning material to absorb falls. Children's toilets and hand washing facilities were sanitary and in good operating condition. Floors in the facility were clean and safe. All kitchen, food preparation and storage areas were clean and free of litter/rubbish. The facility was free of flies, insects, and rodents/vermin. All food was protected against contamination and any contaminated food is discarded immediately. Solid waste storage containers had tight-fitting covers and were in good repair. Menus are posted at least one week in advance where an authorized representative can view them. Drinking water was available both indoors and outdoors. The facility had one or more functioning carbon monoxide detectors that meet statutory requirements. Capacity and limitations as specified on the license are being maintained. The facility maintains a ratio of one teacher supervising no more than 12 children in care. All children are under supervision, including visual supervision, of a teacher at all times. The person who signs the child in/out of the facility shall use their full legal signature and record the time of day. A sample of children's files were reviewed and contained contact information for authorized representative and/or relatives or others who can assume responsibility for the child and medical assessment. LPA also reviewed a sample of staff files and observed they contained health screening, immunization records for influenza, pertussis, and measles and current documentation of completed Mandated Reporter Training. At least one person trained in CPR and pediatric First Aid is present when children are at the facility or at off-site activities.

SUPERVISOR'S NAME: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Angelica Slaughter	TELEPHONE: (559) 341-3920
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

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: POMONA MIGRANT HEAD START	FACILITY NUMBER: 203801343
	VISIT DATE: 08/26/2021

NARRATIVE

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Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review have received a criminal record clearance or exemption. Upon notification from the Department, the facility 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.

This is an all day program which operates Mid-May through October schedule. Hours are Monday through Friday from 8:00 AM to 4:00 PM.

Incidental Medical Services (IMS) are not 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 Amercians 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://ww.ada.gov/chilqanda.htm.

LPA and Director 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, Lead Poisoning Facts, Forms and Regulations.

Director to submit updated copies of the Emergency and Disaster Plan (LIC 610), Personnel Report (LIC 500) and Designation of Responsibility (LIC 308) to the CCLD Office.

Per Title 22, Division 12, Chapter 1 of the California Code of Regulations no deficiencies were observed today.

Exit interview was conducted with Director Lourdes Lugo. LPA provided Director with a copy of the Facility Evaluation Report (LIC 809), appeal rights, and the Notice of Site Visit form (LIC 9213). The LIC 809 is required to remain in the facility for public review and the LIC 9213 is required to be posted for 30 days.

SUPERVISOR'S NAME: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Angelica Slaughter	TELEPHONE: (559) 341-3920
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021

LIC809 (FAS) - (06/04)

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