<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343614395
Report Date: 10/19/2021
Date Signed: 10/19/2021 02:28:28 PM

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:MISSION AVENUE PRESCHOOLFACILITY NUMBER:
343614395
ADMINISTRATOR:DUSTI KIRNFACILITY TYPE:
830
ADDRESS:2433 MISSION AVENUETELEPHONE:
(916) 487-4647
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:22CENSUS: 7DATE:
10/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Dusti KirnTIME COMPLETED:
02:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 1:15 p.m. on Tuesday, October 19th, 2021, Licensing Program Analyst (LPA) Karyn Guerra met with Director, Dusti Kirn, for the purpose of a case management inspection. LPA inspected the refrigerator in the eating room of the infant classroom and observed milk in a labeled container for infant in care. Milk was not prepared in a bottle prior to acceptance by the facility. This poses a potential risk to children in care. Director stated that they will notify families to bring prepared bottles to the facility.

LPA also observed pack and play yards in infant napping area. Technical assistance was conducted. LPA reviewed updated safe sleep regulations with Director.


Title 22 deficiencies are cited on the subsequent pages of this report. An exit interview was conducted and a notice of site visit and appeal rights were provided. Notice of site visit shall remain posted for a period of 30 days for parental review.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: MISSION AVENUE PRESCHOOL
FACILITY NUMBER: 343614395
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2021
Section Cited

1
2
3
4
5
6
7
101427 Infant Care Food Service (e) The infant's authorized representative may provide formula or breast/mother's milk. (1) Such formula or milk shall be bottled before being accepted by the center. This requirement was not met, as evidenced by:
8
9
10
11
12
13
14
Based on observations, milk for infant in care was in a labeld container and not bottled. This poses a potential risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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 LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2