203810070-12-3-2020-04-CC-CROZ-BVXT38-20201203132156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 203810070
Report Date: 12/03/2020
Date Signed: 12/03/2020 01:22:10 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 CHRIST		FACILITY NUMBER:	203810070
ADMINISTRATOR:	HECKMAN, BRENDA		FACILITY TYPE:	840
ADDRESS:	43840 PATRICK AVE		TELEPHONE:	(559) 440-6777
CITY:	COARSEGOLD	STATE: CA	ZIP CODE:	93614
CAPACITY:	42	CENSUS: 12	DATE:	12/03/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Stacey Velazquez		TIME COMPLETED:	02:00 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 12/03/2020, Licensing Program Analyst (LPA) Candis Rodriguez conducted an unannounced Case Management inspection at facility. LPA met with Director Stacey Velazquez, explained purpose of inspection, toured the facility and took a census.

On 11/30/2020, Community Care Licensing (CCL) received notification from facility about an incident that occurred on 11/23/2020 at approximately 10:45am. LPA visited facility on 11/23/2020 to conduct a case management inspection at 12:00pm. Facility did not report incident to LPA while LPA was present at facility.

On 11/23/2020, Child #1 was climbing a small climbing structure when their foot slipped. Child #1 fell down and landed on their feet, then fell back onto their bottom. Facility stated when Child #1 fell, they stated their left foot hurt. Staff observed there was swelling between the ankle and pinky toe. Staff gave Child #1 a piggy back ride inside where the foot was elevated and iced. Facility called Child #1’s mother. After 15 minutes of icing, Child #1 complained it was still hurting and because the swelling did not go down, facility contacted Child #1’s mother again to pick up Child #1. Child #1 was signed out by parent at 11:35am. Child #1’s mother took them to the doctor the same day and got x-rays done which showed a tiny fracture. Child #1 is in a boot and crutches and returned to the facility the next day.

LPA observed the play area where Child #1 was injured. LPA did not observe any holes or uneven surface that would have contributed to the child’s injury. LPA observed the play area to have wood chips for cushioning. LPA reviewed facility files and interviewed Director. There were two staff present at playground and 12 children present at facility. Child #1 was approximately two to three feet from the ground when Child #1 slipped down the climbing structure. Director stated Child #1 was wearing cowboy boots which made Child #1 slip. LPA discussed with Director about having children come to the facility wearing appropriate shoes for play. Director stated she will notify parents and initiate a policy immediately that requires children to be wearing appropriate shoes and attire for outdoor play. (Continued on LIC 809-C)

SUPERVISOR'S NAME: Alice Juarez	TELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Candis Rodriguez	TELEPHONE: (559) 341-4117
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

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 3

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: 12/03/2020

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
26
27
28
29
30
31
32

Facility did not report incident until one week later. Community Care Licensing was open on 11/23, 11/24, and 11/25/2020. An incident report was also filed on 11/02/2020 for an incident that occurred on 10/27/2020. LPA advised Director after both incidents were reported that all incidents should be reported within 24 hours, and if unable to reach LPA to call the main office and report to the Officer of the Day. LPA left a copy of the regulations which state when and for what instances to file an Unusual Incident Report.

Per Chapter 1, Division 12, Title 22 of the California Code of Regulations, the following deficiencies are found: (see LIC809-D). Site Visit Notice posted on the parent board. Exit interview was conducted with Director Stacey Velazquez. Director was provided a copy of appeal rights. This report shall be made available to the public upon request. LIC 9213, Notice of Site Visit, is required to be posted for 30 days.

SUPERVISOR'S NAME: Alice Juarez	TELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Candis Rodriguez	TELEPHONE: (559) 341-4117
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/24/2020 Section Cited	1 2 3 4 5 6 7	101212(d)Upon the occurrence...of any of the events specified in (d)(1)...a report shall be made to the Department by telephone or fax within the Department's next working day...(1)Events reported shall include the following:(B)Any injury to any child that requires medical treatment.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by record review and interview with Director. Based on observation and interview, facility did not report to CCL an injury to child which required medical care. This poses a potential risk to the health, safety, and personal rights of children in care.	8 9 10 11 12 13 14	log to CCL by POC due date.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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 Juarez	TELEPHONE: (559) 650-7857
LICENSING EVALUATOR NAME: Candis Rodriguez	TELEPHONE: (559) 341-4117
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

LIC809 (FAS) - (06/04)

Page: 3 of 3