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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317946
Report Date: 11/16/2021
Date Signed: 11/17/2021 10:10:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:EARL WARREN PRESCHOOLFACILITY NUMBER:
340317946
ADMINISTRATOR:HO, CHELSEAFACILITY TYPE:
850
ADDRESS:5420 LOWELL STREETTELEPHONE:
(916) 382-5934
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:48CENSUS: 21DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Chelsea Ho and Suzie SarabaTIME COMPLETED:
12:50 PM
NARRATIVE
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On Tuesday, 11/16/2021, Licensing Program Analyst (LPA) Tanya Washington conducted an unannounced annual random inspection for the preschool program and met with Facility Representative Chelsea Ho. Upon arrival, LPA observed 16 children from room P2 supervised by two staff members on the playground and five children inside classroom P1 supervised by two staff members. Facility hours of operation in room P2 are Monday -Friday from 8:30 AM to 3:30 PM. Facility hours of operation in room P1 are Monday- Friday from 8:AM to 3:00 PM. Both rooms run two separate programs, Head Start and State Program.
LPA conducted a health and safety inspection inside and outside of the facility. The following areas are in compliance during the visit. Firearms and ammunition are not on the premises. Facility Representative acknowledged that storage area for poisons needs to be locked and stated that there are no poisons on site. Disinfectants, hazardous items and medications are inaccessible to children. Furniture and equipment are sufficient, age appropriate, and in good repair. Fire drills are conducted and documented. Carbon Monoxide detector was present and in working order. The playground equipment and outdoor activity space is maintained and in good condition. Bark is utilized as cushioning around the climbing equipment and is sufficient to absorb a fall. Children's toilets, hand washing facilities are sanitary. Floors are clean and free of debris. Food preparation area is clean, food is protected from contamination, storage containers for solid waste are covered, and all food or beverages are stored in covered containers and labeled. Drinking water is available both indoors and outside. Menus are posted. The facility is in compliance with conditions and limitations specified on the license. Sign in/sign out sheets are maintained. No excluded individuals are present. Staff subject to a criminal record clearance or exemption are cleared through Sacramento Unified School District. At least one staff member had current CPR and First Aid Certification. Emergency information and files were reviewed for five children from room P1 and four children from room P2. LPA reviewed five staff records. Facility provides breakfast, snack and lunch.

REPORT CONTINUED ON NEXT PAGE
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: EARL WARREN PRESCHOOL
FACILITY NUMBER: 340317946
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(6)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 101219.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, upon review of nine children's files, LPA did not observe a copy of the admission agreement which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2021
Plan of Correction
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Facility Representative will ensure all children's files are up to date. LPA will return to review children's records.
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2021
Plan of Correction
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Facility Representative will ensure all children's files are up to date. LPA will return to review children's records.
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: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: EARL WARREN PRESCHOOL
FACILITY NUMBER: 340317946
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101223(b)(1)
Personal Rights
(1) The center shall give each authorized representative a copy of the Personal Rights form (LIC 613A [9/96]).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review of nine children's files, LPA did not observe the required form. The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2021
Plan of Correction
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Facility Representative will ensure all children's files are up to date. LPA will return to review children's records.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: EARL WARREN PRESCHOOL
FACILITY NUMBER: 340317946
VISIT DATE: 11/16/2021
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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 Child Care Centers Sections 101173 and 101226. 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

LPA discussed current COVID guidelines with Facility Representative.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Three Type B Deficiencies are cited on the following LIC809D. LPA reviewed report with the Facility Representative and provided copies. Exit interview conducted and report was reviewed with the facility representative Ahisha Lewis. A notice of site visit was given and must remain posted for 30 days. Appeal rights are provided.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5744
LICENSING EVALUATOR NAME: Tanya WashingtonTELEPHONE: 916-879-1209
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 3 of 4