343616796-9-9-2022-03-CC-KGUA-CJ4Q38-20220909114820

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343616796
Report Date: 09/09/2022
Date Signed: 09/09/2022 11:48:29 AM

Document Has Been Signed on 09/09/2022 11:48 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:	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:	33	CENSUS: 21	DATE:	09/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Anne Marie Duesbury		TIME COMPLETED:	12:00 PM

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At 9:30 a.m. on Friday, September 9th, 2022, Licensing Program Analyst (LPA) Karyn Guerra met with Director, Anne Marie Duesbury, for the purpose of an unannounced, required 1 year inspection. A COVID-19 risk assessment was conducted. Operating hours of the facility are from 8:00 a.m.-5:00 p.m., Monday thru Friday. LPA observed a census of 21 children supervised by 4 staff.

All individuals subject to criminal background review have obtained criminal record clearance. Director 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.

A health and safety inspection was conducted in the classrooms, restrooms, food service areas, and outdoor play areas. LPA observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, menus, and daily schedule. Cleaning disinfectants and hazardous items are appropriately stored and inaccessible to children. Disaster drills are conducted with the main school. Director stated there are no poisons on the premises. Furniture and equipment are in good condition, and toileting facilities are in safe, sanitary, and operating condition. Bins for solid waste have tight fitting lids. The floors appeared clean throughout the facility. The facility provides AM and PM snack. The food preparation space is free of litter and all food was protected against contamination. Drinking water was readily available to children both indoors and outdoors via labeled bottles. LPA observed full legal signatures of authorized representatives in sign in/sign out binders. There are no firearms nor bodies of water on the premises. LPA observed a functional carbon monoxide detector. Playground equipment and surfaces are free of loose or sharp parts. LPA observed wood chip cushioning beneath the

Report continues on 809-C.

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn Guerra	TELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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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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: 09/09/2022

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play structure. Sand box is covered with a tarp when not in use. Outdoor shade is provided by canopies and awnings.

Staff files were reviewed. At least one staff member present today has current Pediatric CPR and First Aid certification. LPA observed immunization records and documentation of the educational background, training, and/or experience and AB 1207 Mandated Reporter training certificates.

Children's records were reviewed. Each child's file contained an emergency card, consent for emergency medical treatment and notifications of children’s and parent’s rights, health history, physician's report and immunization records.

This facility does not provide Incidental Medical Services – IMS. No children in care require medications. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.

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.

A staff interview was conducted with the Director, Anne Marie Duesbury. LPA discussed written directives for lead testing AB2370 and will follow up with an email containing the PIN.

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, no deficiencies were cited during today’s inspection. Exit interview conducted and report was reviewed with Director, Anne Marie Duesbury. 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: Karyn Guerra	TELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC809 (FAS) - (06/04)

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