343616796-8-12-2021-03-CC-GSIH-C5TQ4F-20210812115015

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343616796
Report Date: 08/12/2021
Date Signed: 08/12/2021 11:50:20 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:	OUR LADY OF THE ASSUMPTION		FACILITY NUMBER:	343616796
ADMINISTRATOR:	DUESBURY, ANN MARIE		FACILITY TYPE:	850
ADDRESS:	5055 COTTAGE WAY		TELEPHONE:	(916) 485-1504
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	30	CENSUS: 0	DATE:	08/12/2021
TYPE OF VISIT:	Case Management - Licensee Initiated	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ann Marie Duesbury		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Gagandeep Singh met with the director, Ann Marie Duesbury, for a scheduled case management inspection. The facility requested the Department to inspect two new classrooms and play yard prior to use for child care. The facility will no longer be using the classrooms that were previously used. The facility also requested to increase the children's capacity from 30 to 33. The Department has received the approved fire inspection form from local fire department.

During today's inspection, LPA inspected the facility with the director. The facility will be operating from classroom # 2, classroom # 3 and play yard. LPA observed a variety of age appropriate toys and equipment in the classrooms. All furniture is steady and in good repair. There is first aid kit in each classroom and medications will be stored in the office. Isolation of any sick child will be in the office. Facility has sufficient amount of sleeping matts stored in the storage room. The classrooms have plenty of light and proper temperature. LPA measured both of the classrooms and found the classrooms space contains 1254.81 Sqft, which accommodates the facility's request for 33 children in care. There are four sinks and four toilets available for the children. LPA observed the sink and toilets are in working condition. There is separate restroom for the staff. There is kitchen area. LPA observed the food preparation area is clean with proper sanitization in place. LPA observed facility has working microwave, but the refrigerator is not working today. Per director, the facility will provide snacks and children will be bringing their own meals. There is water dispenser in each classroom to provide the drinking water to the children. During the inspection of play yard, LPA observed play yard has shaded area for the children. There is a sand box in play yard and LPA observed sand box is covered. There is age appropriate play structure, label for children between age of 2 to 5, in the play yard. Play structure is steady and free of any loose parts. There is plenty of wood chips under the play structure to prevent any fall injury. Per director, the staff will bring the children's water bottles to the play yard during the play time. There is metal fence on both ends of the play yard. See next page for continuation .............

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

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: OUR LADY OF THE ASSUMPTION	FACILITY NUMBER: 343616796
	VISIT DATE: 08/12/2021

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The director acknowledges that the following documents must be posted at all times: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, Effects of Lead Exposure, car seat poster, menus, and daily schedule.

LPA measured the play yard. The play yard was measured for 4360.133 Sqft, which accommodate the facility's request for 33 children in care. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

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.

Prior the approval of new classrooms, the facility must have: - Carbon Monoxide detector
- Working refrigerator.

This facility evaluation report was reviewed and discussed with the director. The director was encouraged to the visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to child care centers. Notice of site visit is posted and shall remain posted for next 30 days.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Gagandeep Singh	TELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC809 (FAS) - (06/04)

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