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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343614395
Report Date: 07/13/2022
Date Signed: 07/13/2022 04:35:11 PM


Document Has Been Signed on 07/13/2022 04:35 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:MISSION AVENUE PRESCHOOLFACILITY NUMBER:
343614395
ADMINISTRATOR:DUSTI KIRNFACILITY TYPE:
830
ADDRESS:2433 MISSION AVENUETELEPHONE:
(916) 487-4647
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:22CENSUS: 15DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Christina Diaz BushmanTIME COMPLETED:
04:45 PM
NARRATIVE
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At 12:50 p.m. on Wednesday, July 13th, 2022, Licensing Program Analyst (LPA) Karyn Guerra met with Director, Christina Diaz Bushman, for the purpose of an unannounced Required - 1 Year inspection. A risk assessment for COVID-19 was conducted. Census upon arrival was 7 infant children supervised by 3 staff, and 8 napping toddler children supervised by 1 staff. Hours of operation are 6:00 a.m. to 6:00 p.m., Monday thru Friday.

All individuals subject to criminal background review have obtained criminal record clearance. Director 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.

LPA conducted a health and safety inspection of the classroom, restrooms, and food service areas. LPA observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, car seat laws, menus, and daily schedule. Cleaning disinfectants and hazardous items are appropriately stored and inaccessible to children. Director stated that there are no firearms nor poisons on the premises. LPA observed a changing table within arm's reach of a sink. Changing table has raised sides. Bins for solid waste have tight fitting lids. The floors appeared clean throughout the facility. LPA discussed area rug in the toddler classroom. Infant food is provided by parents/guardians for children under 1. Facility provides breakfast, lunch, and snack for infants 1 and over. LPA observed prepared milk bottles labeled with children's names and the date. Other food in the facility was properly stored to prevent contamination. Drinking water is provided to children via labeled sippy cups. LPA observed sign in and sign out logs with full legal signature of parent/guardians.

This facility provides Incidental Medical Services – IMS. Director understands that a plan of operation must be on file at the facility. 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.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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 07/13/2022 04:35 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: MISSION AVENUE PRESCHOOL
FACILITY NUMBER: 343614395

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2022

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 as several staff files were missing proof of immunizations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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Director will provide documentation of immunizations by POC due date.
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

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 as several staff files were missing a health screening and TB clearance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2022
Plan of Correction
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Director will provide documentation of health screening and TB clearance by POC due date.

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: 07/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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: MISSION AVENUE PRESCHOOL
FACILITY NUMBER: 343614395
VISIT DATE: 07/13/2022
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LPA discussed the safe sleep regulations with Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed DIrector of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Director understands that an individual infant sleeping plan LIC9227 must be on file for all infants up to 12 months of age, and cribs shall be free of loose articles. 15 minute checks of napping infants must be conducted and documented.

LPA conducted a health and safety inspection of the outdoor space. Playground equipment and surfaces were free of loose or sharp parts. LPA observed foam to provide cushioning. Outdoor shade was provided by trees.

LPA reviewed staff and children's records. Each child's file contained an admission agreement, emergency card, health history, immunizations, and acknowledgement of receipt of personal rights, consent for emergency medical treatment, and parent’s rights. LPA observed CPR and First aid certification for at least one staff on the facility premises. LPA did not observe health screening nor immunization records for several staff. LPA observed, employee rights, and documentation of the educational background, training, and/or experience.

A staff interview was conducted with Director, Christina Diaz Bushman. Director stated lead testing of water per AB2370 has been conducted.

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.

Title 22 deficiencies are cited on the subsequent pages of this report. Appeal rights were provided. Exit interview conducted and report was reviewed with the Christina Diaz Bushman. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2022
LIC809 (FAS) - (06/04)
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