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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 240405513
Report Date: 12/19/2019
Date Signed: 12/19/2019 11:42:12 AM

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:ST. PAULS' EVANGELICAL LUTHERAN CHURCH OF MERCEDFACILITY NUMBER:
240405513
ADMINISTRATOR:FAULKNER, ANGELIQUEFACILITY TYPE:
850
ADDRESS:2916 N. MCKEE ROADTELEPHONE:
(209) 383-5672
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY:55CENSUS: 18DATE:
12/19/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Angelique Faulkner - DirectorTIME COMPLETED:
12:00 PM
NARRATIVE
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(2) Licensing Program Analyst, Joseph Pacheco, conducted an unannounced annual/random inspection today. LPA met with Director, Angelique Faulkner, and a tour of the facility was conducted inside and outside. Staff and children were spoken to during visit. The following areas were in compliance during today’s inspection: There are no bodies of water present at this facility. There are no firearms or ammunition allowed on the premises. Disinfectants, hazardous items and medications are inaccessible to children. Storage area for poisons is locked. Furniture and equipment are sufficient, age appropriate and in good repair. The playground equipment and outdoor activity space is maintained and in good condition with adequate cushioning material. Children's toilets, hand washing facilities are sanitary. Rooms are safe and clean. Food preparation area is clean, food and beverages are stored in covered containers at 45 degrees F or less if required, and storage containers for solid waste are covered. Drinking water is available both indoors and outside. Measures are taken to keep facility free of insects and rodents. Staff subject to a criminal record clearance or exemption are associated to the facility. No excluded individuals are present. Teacher-child ratios are maintained and adequate supervision was observed during today’s inspection. First Aid/CPR credentials for staff were reviewed and current. AB 1207 certification for staff is current. Sign in/sign out sheets have not been maintained in accordance with regulations. Children’s records were reviewed to ensure proper forms are located within each child’s file. One staff file did NOT contain documentation of education and immunizations. Menus are posted.

Hours of operation are 7:00am – 5:45pm, Monday through Friday.

Incidental Medical Services (IMS) policy was discussed. Incidental Medical Services (IMS) are not currently being provided. When any IMS is provided, a Plan for Providing 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

CONTINUED ON LIC809-C
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019
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 4
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: ST. PAULS' EVANGELICAL LUTHERAN CHURCH OF MERCED
FACILITY NUMBER: 240405513
VISIT DATE: 12/19/2019
NARRATIVE
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LPA provided Director with information regarding providing incidental medical services to children, the CDSS Provider Information Notices (PINs) communication system, and some important resources and information links offered on the CDSS website.

Per Chapter 1, Division 12, Title 22 of the California Code of Regulations, the following deficiencies are found (see LIC809-D): Copy of appeal Rights left with center Director.

THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST.
LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: ST. PAULS' EVANGELICAL LUTHERAN CHURCH OF MERCED
FACILITY NUMBER: 240405513
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2020
Section Cited

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Sign in and sign out. (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day. (b) The person who brings the child to, and removes the child from, the center shall sign the child in/out.
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This requirement was not met as evidenced by LPA observation of sign in and sign out records. LPA observed seven authorized representatives of children who did not sign in and sign out a child each day. This is a potential risk to the health, safety, or personal rights of children in care.
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protocol enlisted. In addition, Director to disseminate information/advisory notice to parent's informing them of the requirement to sign their children in/out daily. Copy of plan devised, including staff training and advisory notice provided to parents to be submitted to LPA by 01/10/20.
Type B
01/10/2020
Section Cited

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Teacher aide qualifications and duties. (d) An aide assisting a fully qualified teacher…in the supervision of up to 18 preschool-age children…shall meet the following requirements: (1) Completion of six postsecondary semester or equivalent quarter units in early childhood education or child
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development. This requirement was not met as evidenced by LPA observation of one staff file. Facility was unable to provide verification that educational requirements have been met during today’s inspection. This is a potential risk to the 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.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: ST. PAULS' EVANGELICAL LUTHERAN CHURCH OF MERCED
FACILITY NUMBER: 240405513
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2020
Section Cited

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Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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This requirement was not met as evidenced by LPA observation of a staff file that did not contain documentation of the pertussis and measles vaccine. This is a potential risk to the 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.
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Joseph PachecoTELEPHONE: (559) 341-4457
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4