340321380-11-29-2022-03-CC-ASUR-CLMUNQ-20221129144419

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 340321380
Report Date: 11/29/2022
Date Signed: 11/29/2022 02:44:28 PM

Document Has Been Signed on 11/29/2022 02:44 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:	PETER BURNETT PRESCHOOL		FACILITY NUMBER:	340321380
ADMINISTRATOR:	MAI VANG		FACILITY TYPE:	850
ADDRESS:	6032 36TH AVE. RM.#3		TELEPHONE:	(916) 277-6522
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95824
CAPACITY: 24	TOTAL ENROLLED CHILDREN: 24	CENSUS: 16	DATE:	11/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Gulalai Shetab		TIME COMPLETED:	03:00 PM

NARRATIVE

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On Tuesday, November 29, 2022 at 11:29 PM, Licensing Program Analysts (LPAs) Amanda Sutter Soleil Marx met lead teacher Gulalai Shetab for the purpose of an unannounced required annual inspection. LPAs observed 16 children supervised by 3 staff and one volunteer. All individuals subject to criminal background review have obtained a criminal record clearance. The facility hours of operation are Monday through Thursday from 8:00 AM to 2:30 PM and Friday from 8:00 AM to 11:45 PM.

LPAs toured classroom space and outdoor play area. LPAs observed the following documents are posted: License, Emergency Disaster Plan, Parents' Rights Poster, menu, and seat belt law. LPA observed a functional carbon monoxide detector. Cleaning disinfectants, medications and hazardous items are appropriately stored and inaccessible to children. Director stated there are no poisons or firearms on the premises. Furniture and equipment are in good condition, and toileting facilities are in safe, sanitary and operating condition. The program provides breakfast, lunch, and one snack.

LPAs observed trash bins with tight fitted lids. LPAs observed the facility’s paper sign in and out system. Facility has record of conducting fire drills at least every six months; last fire drill was conducted on November 16, 2022. Playground equipment and surfaces are free of loose or sharp parts and rubber is present under the equipment to provide sufficient cushioning. There are sufficient equipment and toys, and shaded areas are supplied by trees and a shade structure. Drinking water is readily available to children both indoors and outdoors. Director stated that the facility uses a pitcher and cups.

Three staff and five children's records were reviewed. There is at least one staff member present with a current CPR certificate.

PAGE 1. REPORT CONTINUES ON LIC809-C

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

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: PETER BURNETT PRESCHOOL	FACILITY NUMBER: 340321380
	VISIT DATE: 11/29/2022

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LPA discussed the safe sleep regulations with director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPAS also informed director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Service (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

Director 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.

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.

During today’s inspection, one type B deficiency was observed. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Lead Teacher Gulalai Shetab.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Amanda Sutter
LICENSING EVALUATOR SIGNATURE:	DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/29/2022 02:44 PM - It Cannot Be Edited

Created By: Amanda Sutter On 11/29/2022 at 02:27 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: PETER BURNETT PRESCHOOL	FACILITY NUMBER: 340321380
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101217(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 3 files reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/29/2022
	Plan of Correction
1 2 3 4	LPA will return to review completed staff files.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Seychelle De Luca

LICENSING EVALUATOR NAME:

Amanda Sutter

LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022

LIC809 (FAS) - (06/04)

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