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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343600372
Report Date: 05/11/2022
Date Signed: 05/11/2022 03:56:41 PM


Document Has Been Signed on 05/11/2022 03:56 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:MERRYHILL SCHOOL-LAGUNA PARKFACILITY NUMBER:
343600372
ADMINISTRATOR:NORRIS, LISAFACILITY TYPE:
850
ADDRESS:6613 LAGUNA PARK DRIVETELEPHONE:
(916) 684-4044
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:116CENSUS: 99DATE:
05/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Karina MedinaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katy Maestas conducted a field visit to the facility on 05/11/2022 for a case management inspection. LPA met with the Director, Karina Medina. LPA toured the facility and observed 11 staff members supervising 99 children. 1 staff member was not associated with the license in Guardian.

LPA had received an Unusual Incident Report (UIR) on 05/03/2022 that described an incident on a play structure which resulted in a broken arm. Licensee reported and submitted the UIR within 7 days. LPA inspected the play structure which appears to be in good condition and is designed for ages 2-5 years old. LPA confirmed that supervision was adequate at the time of injury (2 staff members were supervising) and that ratios were adhered to (24 children) at recess time. Director confirmed that this injury was accidental and that the child slipped off the slide and landed on her elbow which resulted in the injury.

The following Type B citations were given during the inspection on the LIC 809-D page of this report. An exit interview was conducted with the Director and the Licensee Appeal Rights were provided. A Notice of Site Visit was posted by LPA and this shall be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Nola MaestasTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
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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Document Has Been Signed on 05/11/2022 03:56 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: MERRYHILL SCHOOL-LAGUNA PARK
FACILITY NUMBER: 343600372

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2022
Section Cited

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All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:
(2) Request a transfer of a criminal record clearance as specified in Section 101170(f). This requirement was not met as evidenced by:
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during a review of staff records, S1 was not associated to the facility's license. This is a potential health and safety risk to chidlren 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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Nola MaestasTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2022
LIC809 (FAS) - (06/04)
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