313620676-6-2-2023-03-CC-KOWS-CSEM9C-20230602092431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313620676
Report Date: 06/02/2023
Date Signed: 06/02/2023 09:24:38 AM

Document Has Been Signed on 06/02/2023 09:24 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	KASEBERG ELEMENTARY PRESCHOOL		FACILITY NUMBER:	313620676
ADMINISTRATOR:	AMIRA MOHAMED		FACILITY TYPE:	850
ADDRESS:	1040 MAIN STREET		TELEPHONE:	(530) 906-6021
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95678
CAPACITY:	48	CENSUS: 0	DATE:	06/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Amira Mohamed - Site Supervisor		TIME COMPLETED:	09:30 AM

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	An unannounced annual/random inspection is made today by Licensing Program Analyst Owens LPA Owens met with Amira Mohamed, Site Supervisor. This facility is located on Kaseberg Elementary school grounds. The last day of school was yesterday, June 1, 2023. No children were present but 5 staff were present cleaning the classrooms. LPA was allowed to complete the annual inspection. Facility operates a split Title 5 program in the morning in room 25 and a pm program in room 24. The following areas are in compliance during inspection: There are no bodies of water. Firearms and ammunition are not on the premises. Storage area for poisons is locked. Disinfectants, hazardous items and medications are inaccessible to children. Furniture and equipment are sufficient, age appropriate and in good repair. Fire drills are conducted according to Title -22 Regulations. The facility uses the elementary school playground and the elementary school bathrooms. The playground equipment and outdoor activity space is maintained and in good condition. There is adequate shade on the playground. Wood chips is being used as cushioning around the climbing equipment. Classrooms are safe and clean. Carbon Monoxide detector is on the premises. Storage containers for solid waste are covered. The facility provides breakfast, lunch and snack. The food is provided by the Elementary School Cafeteria. Drinking water is available both indoors and outside. Menus are posted. The facility is in compliance with conditions and limitations specified on the license. There is adequate space for children belongings. Napping equipment are in good repair. Sign in/sign out sheets maintained. All waivers are being followed. No excluded individuals are present. Criminal record clearance or exemption are monitored by Department of Education. First Aid/CPR reviewed and in compliance. Emergency information reviewed for some children. Staff records reviewed contain documentation of the educational background, training, and/or experience. Continued on next page.

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Katrina Owens	TELEPHONE: (916) 879-1175
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KASEBERG ELEMENTARY PRESCHOOL	FACILITY NUMBER: 313620676
	VISIT DATE: 06/02/2023

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

Operating hours are Monday thru Friday; Classroom 25 - operates full-time 8:00 AM to 2:30 PM and Classroom 24 has AM and PM class from 8:00 to 11 AM and 12:30 pm to 3:30 PM.
LPA observed proof that all staff/ volunteers have met the requirements of SB 792.

LPA observed that all staff has completed the required mandated reporter training (AB 1207) at website: www.mandatedreporterca.com

Facility is in compliance with Assembly Bill 2370, which required licensed Child Care facilities to test their water for excessive amounts of lead. Testing was completed on 11/16/2022. Facility understands that the lead testing must be conducted every five years from initial testing.

LPA provided the Community Care Licensing website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current in regards to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws childcareadvocatesprogram@dss.ca.gov.

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 Family Child Care Homes Section 102417. 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. No children current on medication.

No deficiencies observed in the areas inspected during today's inspection. This report was reviewed and discussed with the facility representative at the time of the inspection.

A COPY OF THIS REPORT MUST REMAIN IN THE FACILITY FOR PUBLIC REVIEW.
A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Katrina Owens	TELEPHONE: (916) 879-1175
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2