343617619-8-22-2019-03-CC-MLOR-BFASK8-20190822135619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343617619
Report Date: 08/22/2019
Date Signed: 08/22/2019 01:56:27 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:	CHAMPIONS @ ARNOLD ADREANI ELEMENTARY		FACILITY NUMBER:	343617619
ADMINISTRATOR:	SHELLY DUNCAN		FACILITY TYPE:	850
ADDRESS:	9927 WILD HAWK WEST		TELEPHONE:	(916) 647-7269
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY:	39	CENSUS: 24	DATE:	08/22/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Randi Nasca, Director		TIME COMPLETED:	02:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Mai Lor and Kelly Ferrara met with Program Director Randi Nasca for the purpose of an unannounced annual random inspection. The Director was reminded never to exceed the conditions, limitations, and capacity specified on the license. Census included 24 preschool children supervised by three staff. The preschool license operates in portable classroom #2 and #3. The license offers a full day program from 6:30am to 6:00pm in portable classroom #3 and half day from 9:00am to 12:30pm in portable classroom #2. The program utilizes the multipurpose room as needed. A tour of the facility was conducted inside and outside. The following areas are in compliance during the inspection. There are no bodies of water. Disinfectants, hazardous items and medications are inaccessible to children. Furniture and equipment are sufficient, age appropriate and in good repair. Fire drills are conducted and documented with the last one conducted on July 2019. Carbon Monoxide inspected and operable. The playground equipment and outdoor activity space is maintained and in good condition. Wood chips are being used as cushioning around the climbing equipment and level is sufficient to absorb a fall. Children's toilets, hand washing facilities are sanitary. Floors are clean and free of debris. Food preparation area is clean, food is protected from contamination, storage containers for solid waste are covered and all food or beverages are stored in covered containers and labeled. Drinking water is available both indoors and outside. Menus are posted. The facility is in compliance with conditions and limitations specified on the license. Electronic sign in/sign out have full legal signature and record of time of day. Staff subject to a criminal record clearance or exemption are associated to the facility. First Aid/CPR reviewed and in compliance. Children records were reviewed and contained all of the required documentation. Six out of seven staff records did not contain the required immunizations to include pertussis, measles, mumps, and rubeola., and influenza. (Report continues on page 2)

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai Lor	TELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2019

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: CHAMPIONS @ ARNOLD ADREANI ELEMENTARY	FACILITY NUMBER: 343617619
	VISIT DATE: 08/22/2019

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. IMS is provided by this facility. 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.

LPA Lor checked facilities fees and confirmed that it is up to date.

LPA provided the Community Care Licensing website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current in regards to new regulations.

In the areas that were evaluated, a deficiency was observed at the time of the inspection and cited on subsequent LIC 809. Appeal rights provided. An exit interview was conducted and report was reviewed with licensee who stated she understands todays inspection. Notice of Site Visit posted and licensee understands it must remain posted for 30 days.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai Lor	TELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3

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: CHAMPIONS @ ARNOLD ADREANI ELEMENTARY	FACILITY NUMBER: 343617619
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/23/2019 Section Cited	1 2 3 4 5 6 7	...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
	8 9 10 11 12 13 14	vaccination between August 1 and December 1 of each year. This requirement was not met as evidenced by: LPA file review, six out of seven staff did not have proof of immunizations. This poses a potential health and safety risk to children in care	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Mai Lor	TELEPHONE: (916) 491-0182
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2019

LIC809 (FAS) - (06/04)

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