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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343616142
Report Date: 05/20/2019
Date Signed: 05/20/2019 12:34:53 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:SJUSD - FAIR OAKS ANNEXFACILITY NUMBER:
343616142
ADMINISTRATOR:MCMANNIS, DEBBIEFACILITY TYPE:
830
ADDRESS:10700 FAIR OAKS BLVD.TELEPHONE:
(916) 971-5837
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:16CENSUS: 15DATE:
05/20/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Kerra LancasterTIME COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amie Randa met with TOSA Kerra Lancaster for the purpose of an unannounced annual random inspection. TOSA was reminded never to exceed the conditions, limitations and capacity specified on the license. Census included 15 infants and toddlers being supervised by seven staff members; the staff files are housed at the District Office; therefore LPA Randa had to wait for the files to be delivered. Facility hours of operation are Monday through Friday from 7:30 AM to 3:30 PM and operates year round.

LPA toured the building including all activity and classroom spaces, restrooms, food service, and outdoor play areas. Currently, no infants in care require medications. Poisons are not kept on premises. Toxic and hazardous items are inaccessible to children. Furniture and equipment are in good condition. Playground equipment and surfaces are free of loose or sharp parts. Infant changing tables have a padded surface that is washable and at least one-inch-thick, and they have raised sides that are at least three inches high. The floors appeared clean throughout the facility. The food preparation space is free of litter and all food was protected against contamination. LPA observed that storage containers for solid waste and diaper disposal have tight-fitting covers. LPA observed that the infant's bottles are labeled and taken home daily. Program provides breakfast, lunch, and afternoon snacks for toddlers and infants who are on solids. Menus were posted and drinking water was readily available to children both indoors and outdoors. LPA observed parents are signing in/out properly. LPA observed the infant's Needs and Services Plans are current.

Staff and children's records were reviewed. Each child's file contained an emergency card, a medical assessment, and Needs and Services Plan. At least one staff member present today has current Pediatric CPR and First Aid certification (exp. 02/19/2020).

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019
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 4
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: SJUSD - FAIR OAKS ANNEX
FACILITY NUMBER: 343616142
VISIT DATE: 05/20/2019
NARRATIVE
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All staff currently employed with the facility have a criminal record clearance. S1, S2, S3, S4 and S5 were all missing their health screening report and TB clearances. LPA observed staff had documentation of the educational background, training, and/or experience; however S6 did not have a file with her transcript to prove if she is qualified, the other staff member with her was an assistant; therefore LPA Randa could not confirm if there was qualified staff member who had the infant course. LPA observed S6/Sub and S7 did not have a file at all. LPA reminded TOSA that 100% supervision is required at all times, including in the napping room. LPA advised the TOSA on the new Safe Sleep Regulations and SIDS; he stated they are already practiced and understood. LPA observed that sheets are washed daily.

There are no firearms or bodies of water on the premises. LPA observed a functional carbon monoxide detector. LPA reviewed the Department's inspection authority and discussed with TOSA any changes that may occur regarding the TOSA or an employee acting in the director's absence must be reported to department within ten working days.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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.

This facility evaluation report was reviewed and discussed with TOSA. A Notice of Site Visit was provided and should remain posted for a period of 30 days for parental review. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so TOSA can request to be added to the distribution list to receive Quarterly Updates. Designee was encouraged to the visit the department's website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, THREE TYPE B deficiencies were observed at the time of the visit.

SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: SJUSD - FAIR OAKS ANNEX
FACILITY NUMBER: 343616142
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2019
Section Cited
CCR
101217(a)
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Personnel records shall be maintained on the licensee, administrator, and each employee, and shall contain specified information. This evidence was not met due to LPA Randa
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POC: TOSA stated she would create a file for ALL employes and make them assessable by licensing within two hours of the inspection. TOSA will scan LPA all required documents for S6 and
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observing that S6 and S7 did not have a file at all; which is a potential risk to children in care.
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S7 by the POC due date of 06/21/2019.
Type B
05/20/2019
Section Cited
CCR
101216(g)(2)
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(g) All personnel, including the licensee, administrator and volunteers, shall be in good health and shall be physically and mentally capable of performing assigned tasks (2) above shall
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POC: TOSA stated she would obtain a Health Screening LIC 503 for all employees. TOSA will scan them to LPA by the POC due date of 06/21/2019.
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have a health-screening report signed by the person performing the screening. This evidence was not met due to LPA Randa observing that S1 through S5 did not the LIC 503; which is a potential risk to children in care.
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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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: SJUSD - FAIR OAKS ANNEX
FACILITY NUMBER: 343616142
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/20/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2019
Section Cited
CCR
101616.2(d)
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(d) Original certified copies of transcripts verifying the completion of the required units shall be filed in each teacher's personnel file. This evidence was not met due to LPA Randa
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POC: TOSA stated she would obtain S6's transcripts and scan them to LPA by the POC due date of 06/21/2019.
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observing that S6 did not have her transcripts and LPA could not confirm if she had the infant course; which is a potential risk to children in care. S6 stated she does have the course.
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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: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4