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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 203810070
Report Date: 11/23/2020
Date Signed: 11/23/2020 01:51:53 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:YOSEMITE LAKES COMMUNITY CHURCH KIDS IN CHRISTFACILITY NUMBER:
203810070
ADMINISTRATOR:HECKMAN, BRENDAFACILITY TYPE:
840
ADDRESS:43840 PATRICK AVETELEPHONE:
(559) 440-6777
CITY:COARSEGOLDSTATE: CAZIP CODE:
93614
CAPACITY:42CENSUS: 11DATE:
11/23/2020
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Stacey VelazquezTIME COMPLETED:
02:10 PM
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On 11/23/2020, Licensing Program Analyst (LPA) Candis Rodriguez conducted an announced Case Management Inspection. LPA contacted Director Stacey Velazquez prior to visit to ensure facility did not have anyone who had tested positive or exposed to COVID-19. LPA explained purpose of inspection and took a census.

On 11/02/2020, facility submitted an incident report regarding Child #1 and Child #2 who had bumped into each other while running on 10/27/2020. Facility reported Child #1 sustained an injury to their left eyebrow area. Director stated first aid was administered, including an ice pack, and parent was notified immediately. Director stated parent took Child #1 to the hospital where they received two stitches. LPA reviewed facility files and observed Child #1 was back in the facility the next day. Child #2 did not sustain any injury. LPA observed the area where Child #1 and Child #2 were running, which is a large, wide deck attached to the portable classrooms of the facility. Director stated Staff #1 and Staff #2 were present during this incident. Director stated Staff #1 directly witnessed the incident, as she was standing approximately 10 feet away from where the incident occurred. Staff #1 was not present today, and was unable to be interviewed at this time. LPA interviewed Staff #2, who stated she did not witness the incident because she was not in view of where the incident occurred. Director stated it is common for children to run and play on the deck, as they do not have a designated play area, other than the preschool playground which is shared and only used in the morning or afternoon when the preschool is not utilizing it. Director stated the deck area is commonly used for activities due to it being their only designated outdoor area they can utilize frequently. LPA observed the deck to be in good shape, with no tripping hazards. LPA observed the decking to be a non-slip, composite decking (not wood) later identified as "Trex" decking. LPA reviewed facility files and determined facility was within ratio and capacity on 10/27/2020, and during the time of incident.
(Continued on LIC 809-C)
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Candis RodriguezTELEPHONE: (559) 341-4117
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
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: YOSEMITE LAKES COMMUNITY CHURCH KIDS IN CHRIST
FACILITY NUMBER: 203810070
VISIT DATE: 11/23/2020
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On 11/13/2020, facility submitted an incident report regarding Child #3 who was running in the playground area through wood chips and hurt their ankle on 11/12/2020. Facility reported Child #3 was experiencing pain and parent was contacted immediately. Director stated Child #3 did not appear to be in too much pain, and parent of Child #3 decided to wait and did not pick up Child #3 until a few hours later when facility contacted parent again to report the pain was not getting better. Facility reported after parent took Child #3 to the hospital, it was determined Child #3 broke their ankle and required a cast. LPA reviewed facility files and observed Child #3 returned to facility the next day. Director stated Staff #2 and Staff #3 were present at the time of incident, and Staff #2 witnessed it directly. LPA interviewed Staff #2, who stated she saw Child #3 running through the wood chip area and witnessed the very end of their fall to the ground. Staff #2 stated she asked Child #3 if they were hurt, and Child #3 stated their ankle hurt. Staff #2 had Child #3 sit out with her, and Director assisted Child #3 to the classroom from the playground. Director and Staff #2 applied an ice pack and contacted parent. Staff #2 stated Staff #3 was also present on the playground at the time but did not see the incident. LPA observed the playground and area Child #3 was seen running, and LPA did not observe any tripping hazard that would have contributed to Child #3 falling. LPA observed the wood chips evenly covering the ground, and did not observe any holes or other hazards. LPA reviewed facility files, and determined facility was within ratio and capacity requirements on 11/12/2020 and during time of incident.

Per California Code of Regulations Title 22, Division 12, no deficiency to be cited during today's visit.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Alice JuarezTELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Candis RodriguezTELEPHONE: (559) 341-4117
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
LIC809 (FAS) - (06/04)
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