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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343602289
Report Date: 11/22/2019
Date Signed: 11/22/2019 11:08:34 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:ENCINA HEAD START STATE PRESCHOOLFACILITY NUMBER:
343602289
ADMINISTRATOR:WILLIAMS, LAURAFACILITY TYPE:
850
ADDRESS:1400 BELL STTELEPHONE:
(916) 971-7375
CITY:SACRAMENTOSTATE: CAZIP CODE:
95825
CAPACITY:48CENSUS: 31DATE:
11/22/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kim RoddaTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Marea Behvand met with Facility Designee Kim Rodda for an unannounced case management inspection to discuss the Unusual Incident Report submitted by the program on 11/15/2019 pertaining to an incident that occurred at the facility on 11/14/2019. During the inspection, LPA observed 31 preschool children supervised by 5 staff members.

Title 22 deficiency is cited on the subsequent page of this report.
Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, Licensee shall post LIC 809D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 and Appeal Rights were provided.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Marea BehvandTELEPHONE: (916) 216-7793
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2019
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: ENCINA HEAD START STATE PRESCHOOL
FACILITY NUMBER: 343602289
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/25/2019
Section Cited

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Care And Supervision No Child(ren) shall be left without supervision, including visual supervision except as specified in sections 101216.2(e)(1) and 101230(c)(1).
This requirement is not met as evidenced by:
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Based on receipt of a UIR submitted by the facility to report an Unauthorized Absence, facility failed to provide supervision to prevent a day care from exiting the facility, which poses an immediate Health and Safety risk to children 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: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Marea BehvandTELEPHONE: (916) 216-7793
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2019
LIC809 (FAS) - (06/04)
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