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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343616142
Report Date: 03/03/2023
Date Signed: 03/03/2023 10:58:35 AM


Document Has Been Signed on 03/03/2023 10:58 AM - 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: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: 14DATE:
03/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Angelica DennisTIME COMPLETED:
11:05 AM
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Licensing Program Analysts (LPA) Lea Habtom arrived at the facility and met with Joyce Roth, assigned director, for a required 1-year unannounced annual inspection. During the inspection, Angelica Dennis, Teacher on Special Assignment (TOSA), arrived at the facility to assist LPA with inspection. LPA toured the facility inside and out including all activity and classroom spaces, restrooms, food service and outdoor play areas. LPAs observed 7 infants and 7 toddlers supervised by 6 staff. Hours hours of operation are Monday through Friday from 8:00 AM to 3:00 PM.

Toxic and hazardous items are appropriately stored and inaccessible to infants. Furniture and materials are in good condition. Playground equipment and surfaces are free of loose or sharp parts. Infant changing tables are in safe/sanitary condition, and within arms reach of a sink. Sufficient napping equipment was available. LPA reminded the Director that napping infants must have 100% visual supervision at all times. The food preparation space is free of litter. All food was protected against contamination. Trash cans containing solid waste had lids. Uncontaminated drinking water was readily available to children both indoors and outdoors. Menus were posted and sign in sign out was verified. LPAs also discussed the requirement of washing children's bedding at least once daily. No medication was on site during today's inspection.



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.

Report continued on 809-C
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023
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: SJUSD - FAIR OAKS ANNEX
FACILITY NUMBER: 343616142
VISIT DATE: 03/03/2023
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Three toddler and three infant files were reviewed. Quarterly updated Needs & Services plans were observed. And Individual Sleep Plans (LIC 9227) were discussed. Four staff records were reviewed. All staff currently present at the facility has obtained a criminal record clearance through the San Juan Unified School District. A health screening report, and three child development units in infant/toddler care for an infant teacher was observed. At least one staff member present today has current Pediatric CPR and First Aid training certification. Completion of AB1207 Mandated Reporter Training was verified for staff. The training is free of cost and available at: http://www.mandatedreporterca.com/ Director understands that the certificate must be renewed every two years and proof of completion must remain in the employee’s file. No baby walkers, infant bouncers, saucer chairs, Johnny Jumpers, or taco sleepers were observed on the premises. There are no firearms or bodies of water on the premises. Two staff

LPA reviewed Departments inspection authority and discussed with designee any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] 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



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.html
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
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: SJUSD - FAIR OAKS ANNEX
FACILITY NUMBER: 343616142
VISIT DATE: 03/03/2023
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LPA discussed Assembly Bill 2370, which will require licensed Child Care facilities to test their water for excessive amounts of lead. Testing will be required beginning January 1st, 2020 to January 1st, 2023 and must be conducted every five years from initial testing.

One Title 22 deficiency was cited during today's inspection on 809-D.



Exit interview conducted and report was reviewed with the Angelica Dennis. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/03/2023 10:58 AM - 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: SJUSD - FAIR OAKS ANNEX
FACILITY NUMBER: 343616142

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023

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 in that two staff did not have proof of immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2023
Plan of Correction
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LPA L. Habtom asked Angelica Dennis to email a copy of the immunizations by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023
LIC809 (FAS) - (06/04)
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