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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343616737
Report Date: 08/10/2022
Date Signed: 08/10/2022 01:42:20 PM


Document Has Been Signed on 08/10/2022 01:42 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:CALVARY CHRISTIAN SCHOOL-AGE CAREFACILITY NUMBER:
343616737
ADMINISTRATOR:ARRIAGA, SUSANFACILITY TYPE:
840
ADDRESS:4911 47TH AVENUETELEPHONE:
(916) 393-3633
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY:40CENSUS: 15DATE:
08/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Hope CamarenaTIME COMPLETED:
01:45 PM
NARRATIVE
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On 8/10/22, Licensing Program Analysts (LPAs) Amanda Sutter and Karyn Guerra arrived at the facility to investigate a complaint. At 12:11 AM, LPAs observed 2 children (C1, C2) unsupervised on the the gated blacktop area around the corner from the playground area. LPAs observed a teacher (T1) supervising 13 children. Lead Teacher Hope Camarena called another teacher (T2) to come supervise the children. C1 was observed in blacktop area unsupervised again and told to return to the playground area. At 12:49 PM, LPAs observed 2 children in bathroom washing hands unsupervised.

A notice of site visit was given and must remain posted for 30 days. Based on the inspection, two type A citations have been issued. Exit interview conducted and report was reviewed with facility representative Hope Camarena.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Amanda SutterTELEPHONE: (916) 261-8918
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
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 08/10/2022 01:42 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: CALVARY CHRISTIAN SCHOOL-AGE CARE
FACILITY NUMBER: 343616737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited

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(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time...(1). Supervision shall include visual observation.
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This requirement is not met as evidenced by:

LPAs observed 2 children unsupervised on blacktop area near playground.
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Type A
08/10/2022
Section Cited

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(1) A teacher shall supervise no more than 14 children or with an aide a maximum of 28 children.
This requirement is not met as evidenced by:
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Teacher was observed supervising 15 school age children alone.
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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: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Amanda SutterTELEPHONE: (916) 261-8918
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
LIC809 (FAS) - (06/04)
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