343614520-10-13-2021-03-CC-JHOA-C7RPU5-20211013113659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343614520
Report Date: 10/13/2021
Date Signed: 10/13/2021 11:37:09 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:	ISABELLE JACKSON ELEMENTARY SCHOOL		FACILITY NUMBER:	343614520
ADMINISTRATOR:	FINE, MARTIN		FACILITY TYPE:	850
ADDRESS:	8351 CUTLER WAY		TELEPHONE:	(916) 689-2115
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	40	CENSUS: 21	DATE:	10/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Lisa Tang		TIME COMPLETED:	11:50 AM

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	On Wednesday, 10/13/2021, Licensing Program Analyst (LPA) Jan Hoshida conducted an unannounced annual random inspection for the preschool program and met with Teacher Lisa Tang. Upon arrival, LPA observed 21 children supervised by three staff members. The facility only operates in the K1 room as a half day preschool program and the two classes operate from Monday through Friday from 7:45 to 10:45am and 11:30am to 3:00pm. LPA conducted a health and safety inspection inside and outside of the facility. The following areas are in compliance during the visit. Firearms and ammunition are not on the premises. Teacher acknowledged that storage area for poisons needs to be locked and stated that there are no poisons on site. Disinfectants, hazardous items and medications are inaccessible to children. Furniture and equipment are sufficient, age appropriate, and in good repair. Fire drills are conducted and documented. Carbon Monoxide detector was present and in working order. The playground equipment and outdoor activity space is maintained and in good condition. Wood chips are being used as cushioning around the climbing equipment and level is sufficient to absorb a fall. Children's toilets, hand washing facilities are sanitary. Floors are clean and free of debris. Food is protected from contamination, and all food or beverages are stored in covered containers and labeled. Drinking water is available both indoors and outside. Menus are posted. The facility is in compliance with conditions and limitations specified on the license. Sign in/sign out sheets are maintained. First Aid/CPR reviewed and in compliance. Emergency information reviewed for some children. Facility provides breakfast, lunch, and afternoon snack for children to take home. LPA discussed current COVID-19 guidelines with Director and emailed COVID-19 child care guidance and information. LPA observed that staff and children were wearing masks. *REPORT CONTINUED ON NEXT PAGE*

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Jan Hoshida	TELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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: ISABELLE JACKSON ELEMENTARY SCHOOL	FACILITY NUMBER: 343614520
	VISIT DATE: 10/13/2021

NARRATIVE

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LPA reviewed some staff records and observed that there were not staff files for substitutes were available for review. Teacher stated that she will obtain the licensing files for substitutes (Mandated Reporter training, immunizations, and all required Licensing documents) and submit them to LPA.

This facility provides Incidental Medical Services – 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 Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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.

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.

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.

In the areas that were evaluated, deficiencies were observed at the time of the visit and cited on LIC 809-D. Exit interview conducted and report was reviewed with the facility representative Lisa Tang. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Jan Hoshida	TELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: ISABELLE JACKSON ELEMENTARY SCHOOL	FACILITY NUMBER: 343614520
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101217(d)

Personnel Records

(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by having one out of three files for staff which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2021
	Plan of Correction
1 2 3 4	Teacher stated that they will obtain the licensing files for substitutes (Mandated Reporter training, immunizations, and all required Licensing documents) and submit them to LPA by POC due date of 11/15/21.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Jan Hoshida	TELEPHONE: (916) 917-6572
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC809 (FAS) - (06/04)

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