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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343621948
Report Date: 06/11/2019
Date Signed: 06/11/2019 04:19:21 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:ZEHNDER RANCH SCHOOL AGE PROGRAMFACILITY NUMBER:
343621948
ADMINISTRATOR:DE LA CRUZ, JACKIELYNFACILITY TYPE:
840
ADDRESS:9880 DENALI CIRCLETELEPHONE:
(916) 286-7865
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:70CENSUS: 51DATE:
06/11/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:37 PM
MET WITH:Tiffany Williamson, Assistant Site SupervisorTIME COMPLETED:
04:25 PM
NARRATIVE
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Licensing Program Analysts (LPA) Amy Silva and Joleen Kenney conducted a case management inspection and met with Assistant Site Supervisor, Tiffany Williamson. The purpose of the inspection was in follow up to the Unusual Incident Report (UIR) that was submitted by the facility to Community Care Licensing on June 4, 2019. The UIR was for an incident that occurred on May 31, 2019 when child #1 was observed by an individual to be outside the classroom on the ramp to the building unsupervised. It was stated that staff were unaware that child #1 was outside of the classroom until they were informed by the individual.

Type A deficiency was cited and a civil penalty of $500 was assessed on the following pages of this report for absence of supervision.

Upon receipt of a Type A citation, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. The LIC 9224 must be signed by parents/guardians and kept as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 is available on the website. If the LIC 9224 is not used, the licensee shall prepare a statement indicating the documents have been provided. Licensee shall require the parent/guardian to sign and date the statement and shall keep the signed statement as receipt. Verification of receipt shall be kept in each child's file at the facility.

Notice of Site Visit was provided and posted. Appeal Rights were provided and an exit interview was conducted.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Amy SilvaTELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
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: ZEHNDER RANCH SCHOOL AGE PROGRAM
FACILITY NUMBER: 343621948
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2019
Section Cited
CCR
101229(a)(1)
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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs. No child shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Site Supervisor stated that staff have completed a health and safety module training regarding supervision. Training sign in sheet was provided to LPA during the visit.
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This requirement is not met as evidenced by: The facility reported that Child #1 was left outside the classroom without staff's knowledge. This is an immediate health and safety risk to children in care.
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POC cleared at today's visit.


A Civil Penalty in the amount of $500.00 was assessed for absence of supervision.
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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: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Amy SilvaTELEPHONE: (916) 926-9100
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
LIC809 (FAS) - (06/04)
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