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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343602581
Report Date: 03/11/2022
Date Signed: 03/11/2022 02:52:48 PM


Document Has Been Signed on 03/11/2022 02:52 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:ANTELOPE CHRISTIAN ACADEMY PRESCHOOLFACILITY NUMBER:
343602581
ADMINISTRATOR:CAROLYN HEWETTFACILITY TYPE:
850
ADDRESS:4533 ANTELOPE ROADTELEPHONE:
(916) 722-6169
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:90CENSUS: 38DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Carolyn HewettTIME COMPLETED:
03:05 PM
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Licensing Program Analysts (LPAs) Fabiola Diaz and Erwin Thjia met with Facility Representative Carolyn Hewett for an unannounced annual random inspection. Upon arrival, LPAs observed 38 children. Facility hours of operation are Monday through Friday (6 AM to 6 PM). Facility Representative was reminded never to exceed the conditions, limitations and capacity specified on the license.

LPAs toured all activity and classroom spaces, restrooms, and outdoor play areas. No medications were observed. Facility Representative stated there are no poisons on the premises. LPAs observed disinfectants and hand sanitizers stored at the bottom of the shelf that was not locked, making accessible to children. Furniture and equipment are in good condition. Playground equipment and surfaces are free of loose or sharp parts. The areas around or under climbing equipment are cushioned with bark to absorb the fall, except for under the slide. Facility Representative explained that they are working on ordering the bark, now that it has stopped raining. LPA provided a technical advisory. Toileting facilities are in safe, sanitary, and operating condition. The floors appeared clean throughout the facility. Facility does not provided food, as children bring it from home. Storage containers with solid waste have tight-fitting covers. Drinking water is readily available to children both indoors and outdoors. LPAs observed sign-in and sign-outs with legal signatures.

Five staff and 12 children's records were reviewed. Each child's file contained an emergency card. At least one staff member present today has current Pediatric CPR and First Aid certification. All staff currently employed with the facility have a criminal record clearance, health screening report, and documentation of the educational background, training, and/or experience. 1 out of 5 staff files were missing immunization records. 4 out 5 staff files did not have their Mandated Reporter in file. Facility Representative stated that they are all working on updating their Mandated Reported training. A technical advisory note was provided.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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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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: ANTELOPE CHRISTIAN ACADEMY PRESCHOOL
FACILITY NUMBER: 343602581
VISIT DATE: 03/11/2022
NARRATIVE
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There are no firearms or bodies of water on the premises. LPAs observed a functional carbon monoxide detector. LPAs reviewed the Department's inspection authority and discussed with Facility Representative any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

Incidental Medical Services are being offered– 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

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.

Facility Representative 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.

Facility Representative was encouraged to the visit the departments website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining child care centers.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
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: ANTELOPE CHRISTIAN ACADEMY PRESCHOOL
FACILITY NUMBER: 343602581
VISIT DATE: 03/11/2022
NARRATIVE
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LPAs informed Carolyn Hewett that this report dated 3/11/22 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care. Also, LPAs informed the licensee to provide a copy of this licensing report dated 3/11/22 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview was conducted and report was reviewed with Facility Representative. A Notice of Site Visit was provided and should remain posted for a period of 30 days. See LIC809-D for deficiencies.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/11/2022 02:52 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: ANTELOPE CHRISTIAN ACADEMY PRESCHOOL
FACILITY NUMBER: 343602581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

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 which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed disinfectants and hand sanitizers stored at the bottom of the shelf that was not locked, making accessible to children.
POC Due Date: 03/12/2022
Plan of Correction
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POC was corrected on today's visit. LPA observed all disinfectants and hand sanitizers to be made inaccessible to children in care.
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: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 03/11/2022 02:52 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: ANTELOPE CHRISTIAN ACADEMY PRESCHOOL
FACILITY NUMBER: 343602581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs observed 1 out of 5 staff files missing immunization records.
POC Due Date: 04/11/2022
Plan of Correction
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Facility Represenative will provide LPA with a complete staff's file, including the staff's immunizations.
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: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7