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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340319284
Report Date: 05/05/2023
Date Signed: 05/05/2023 12:57:35 PM


Document Has Been Signed on 05/05/2023 12:57 PM - It Cannot Be Edited

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:SKYCREST STATE PRESCHOOLFACILITY NUMBER:
340319284
ADMINISTRATOR:WILLIAMS, JONNAFACILITY TYPE:
850
ADDRESS:5641 MARIPOSA AVENUETELEPHONE:
(916) 867-2103
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:48CENSUS: 20DATE:
05/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Gail KozaikuTIME COMPLETED:
01:10 PM
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At 11:20 a.m. on Friday, May 5th, 2023, Licensing Program Analyst (LPA) Karyn Guerra met with Teacher, Gail Kozaiku, for the purpose of a required - 1 year inspection. LPA observed a census of 20 preschool children supervised by 4 staff in Classroom C1. Hours of operation for the program are from 8:00 a.m. - 2:30 p.m., Monday thru Friday. Minimum day is on Thursdays with closure 11:45 a.m. Program operates in classrooms C1 and C2, and receives state funds. Classroom C2 is not currently in operation due to staffing.

Criminal record clearance is on file with San Juan Unified School District. Teacher was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A health and safety inspection was conducted in the classrooms, restrooms, food service areas, and outdoor play areas. LPA observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, menus, and daily schedule. Cleaning disinfectants and hazardous items are appropriately stored and inaccessible to children. Medications are stored, inaccessible to children. Teacher stated there are no poisons on the premises. Furniture and equipment are in good condition, and toileting facilities are in safe, sanitary, and operating condition. Bins for solid waste in the have tight fitting lids. LPA observed staining on area rugs in classroom C1. The facility provides breakfast and lunch. Food is centrally prepared in the school kitchen. Drinking water was readily available to children both indoors and outdoors via drinking fountains and pitchers/cups. LPA discussed lead testing of drinking and cooking water. Facility uses an online application for sign in and sign out. There are no firearms nor bodies of water on the

Report continues on 809-C.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: SKYCREST STATE PRESCHOOL
FACILITY NUMBER: 340319284
VISIT DATE: 05/05/2023
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premises. LPA observed a functional carbon monoxide detector. Playground equipment and surfaces are free of loose or sharp parts. LPA observed wood chip cushioning beneath the play structure. Outdoor shade is provided by a permanent canopy structure.

Staff files were reviewed. It was stated that Pediatric CPR and First Aid certification was renewed within the last year. LPA observed immunization records and documentation of the educational background, training, and/or experience and AB 1207 Mandated Reporter training certificates.

Children's records were reviewed. Each child's file contained an emergency card, consent for emergency medical treatment and notifications of children’s and parent’s rights, health history, physician's report and immunization records.

This facility provides Incidental Medical Services – IMS. A plan of operation is on file at the facility. 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. LPA observed individualized health plans with stored IMS medications.

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.

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.

Title 22 deficiencies are cited on the subsequent pages of this report. Appeal rights were provided. Exit interview conducted and report was reviewed with Teacher, Gail Kozaiku. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/05/2023 12:57 PM - It Cannot Be Edited

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: SKYCREST STATE PRESCHOOL
FACILITY NUMBER: 340319284

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238.3(b)
Indoor Activity Space
(b) The floors of all rooms shall have a surface that is safe and clean.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPA observed staining on area rugs in classroom C1, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/05/2023
Plan of Correction
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Director or Licensee Representative will provide photo documentation of cleaned rugs, work order for cleaning, or evidence of disposal by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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