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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343608220
Report Date: 07/17/2024
Date Signed: 07/17/2024 02:11:56 PM


Document Has Been Signed on 07/17/2024 02:11 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MERRYHILL SCHOOL - HARBOUR POINTFACILITY NUMBER:
343608220
ADMINISTRATOR:STEPHANIE GILLFACILITY TYPE:
830
ADDRESS:9561 HARBOUR PT. DRIVETELEPHONE:
(916) 683-3244
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:30CENSUS: 17DATE:
07/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Stephanie GillTIME COMPLETED:
03:30 PM
NARRATIVE
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On 07/17/2024, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit to the facility for the purpose of a Case Management inspection regarding a self reported Unusual Incident Report (UIR) dated 07/15/2024. LPA arrived at the facility and was met by Director Stephanie Gill (D1). LPA disclosed the purpose of the inspection and was granted entrance. LPA toured the facility and observed 17 infants being supervised by 5 staff members during nap time. LPA determined, through accessing Guardian, that all required adults were background cleared and associated to the license.

On 07/11/2024, a staff member served a bottle to the incorrect child. The child ingested approximately 1 ounce before the mix-up was realized and the bottle was removed. This poses/posed a potential risk to the health and safety of children in-care. A Type-B deficiency was cited on a subsequent 809-D page. An exit interview was conducted, and the report was reviewed with Director Gill. LPA provided D1 with Licensee Appeal Rights. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Katy VelazquezTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
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 07/17/2024 02:11 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: MERRYHILL SCHOOL - HARBOUR POINT
FACILITY NUMBER: 343608220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2024
Section Cited
CCR
10142(c)

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Infant Care Food Service...(c) The infant shall be fed in accordance with the individual plan.
This requirement was not met as evidenced by a child being served the incorrect bottle on 07/11/2024.
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Director Gill (D1) created a face-to-name bottle check procedure. The staff were trained on the new procedure on 07/15/2024. D1 supervised that the staff are implementing the new procedure on 07/17/2024. D1 provided LPA with a Face-to-Bottle Observation checklist.
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This poses/posed a potential health, safety, or personal rights risk to persons in-care.
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LPA cleared the citation at the time of the field visit.

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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: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Katy VelazquezTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 07/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2024
LIC809 (FAS) - (06/04)
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