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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623051
Report Date: 10/06/2021
Date Signed: 10/06/2021 11:54:42 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:KIDS PARK-FOLSOM(PS)FACILITY NUMBER:
343623051
ADMINISTRATOR:NASLUND, JULIAFACILITY TYPE:
850
ADDRESS:1111 RILEY STREETTELEPHONE:
(916) 293-8786
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:60CENSUS: 12DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ladan KavanTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kelly Ferrara and Alize Tillery met with Facility Representative Ladan Kavan for an unannounced annual inspection on October 6th, 2021. At 8:45 AM, LPAs toured the facility including all activity and classroom spaces, restrooms, and food service. Appropriate ratio and care and supervision were observed during today's inspection. Census included 20 children being supervised by three staff. Facility Representative was reminded never to exceed the conditions, limitations and capacity specified on the license. Facility hours of operation are Monday through Friday 7:30 AM-8 PM, Saturday 9 AM-9 PM, and Sunday 11 AM- 6 PM.

LPAs reviewed criminal record clearances for all staff present at the facility and LPAs observed that Staff #1 was not on the roster of cleared staff. LPAs contacted the regional office and learned that Staff #1 was cleared but not associated to the facility.

Classrooms all appeared clean including the carpets and floor. Chemicals were kept inaccessible to children in a storage room. There is an indoor gross motor area for the children to use in place of an outdoor playground (waiver on file). Uncontaminated drinking water was readily available to the children. Bathrooms were clean and all sinks and toilets were in operating condition. There are no firearms or bodies of water on the premises and the facility has at least one functioning smoke and carbon monoxide detector. LPAs observed all required licensing documentation was posted for parental review. LPAs observed that parents are signing their children in and out of the center. LPAs discussed current Covid guidelines with the Facility Representative.

At 9:30 AM, children and staff files were reviewed. LPAs reviewed staff transcripts and observed all staff caring for children were qualified. At least one staff had a current Pediatric CPR and First Aid certification which expires July 2023. During staff file reviews, LPAs observed that two out of three files were missing a current Mandated Reporter certificate and three out of three files were missing a Health Screen report (LIC503). LPAs observed that two out of three staff were missing proof of immunizations.

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
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: KIDS PARK-FOLSOM(PS)
FACILITY NUMBER: 343623051
VISIT DATE: 10/06/2021
NARRATIVE
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There is a waiver on file for immunizations for children based on the facility being a drop in center. Other documentation was present for children. LPAs observed a current children's roster and a fire drill log. There is First Aid equipment available.

Incidental Medical Services (IMS) are provided by this facility. For additional IMS information, Director was advised to 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.

The facility evaluation report was reviewed and discussed with the Facility Representative. She was encouraged to the visit the department's website at WWW.CCLD.CA.GOV for information regarding child care updates, PINs, forms, regulations and legislation pertaining to child care centers.

Citations issued are on the following 809-D. Facility Representative acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, Director shall post LIC 809 D with Type A deficiencies for 30 days 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. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 and Appeal Rights were provided.

A notice of site visit was provided and should remain posted for a period of 30 days for parental review.

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: KIDS PARK-FOLSOM(PS)
FACILITY NUMBER: 343623051
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of three staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2021
Plan of Correction
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Licensee shall follow up with paperwork submitted to the Sacramento Regional office and verify that staff #1 has been associated to the facility.
Type A
Section Cited
CCR
101170(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above regarding staff Rasha Maarouf which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2021
Plan of Correction
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Licensee shall follow up with paperwork submitted to the Sacramento Regional office and verify that Rasha Maarouf has been associated to the facility.
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: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: KIDS PARK-FOLSOM(PS)
FACILITY NUMBER: 343623051
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, 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 vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in two out of three staff missing proof of immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2021
Plan of Correction
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Licensee shall obtain proof of immunizations for staff and have a copy placed into each staff's file.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of three staff missing their Mandated Reporter certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2021
Plan of Correction
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Licensee shall have all staff complete the Mandated Reporter training at mandatedreporterca.com and obtain a certificate for each staff file.
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: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: KIDS PARK-FOLSOM(PS)
FACILITY NUMBER: 343623051
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of three cases where staff did not have an LIC 503 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2021
Plan of Correction
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Licensee shall have all staff complete an LIC 503 at their doctor's office and provide the form to the facility for their staff file by POC due date.
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of three cases where staff did not have an LIC 503 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2021
Plan of Correction
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Licensee shall have all staff complete an LIC 503 at their doctor's office and provide the form to the facility for the staff file by POC due date.
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: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5