343623875-3-22-2022-03-CC-ETJA-CCRR83-20220322124715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343623875
Report Date: 03/22/2022
Date Signed: 03/22/2022 12:47:24 PM

Document Has Been Signed on 03/22/2022 12:47 PM - 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:	4TH R - PASO VERDE		FACILITY NUMBER:	343623875
ADMINISTRATOR:	DJALILI, MARIA		FACILITY TYPE:	840
ADDRESS:	3883 DEL PASO ROAD		TELEPHONE:	(916) 566-4496
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95834
CAPACITY:	150	CENSUS: 0	DATE:	03/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jessica Galindo and Nick Ebling		TIME COMPLETED:	01:00 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	On March 22, 2022, at 09.30 am, Licensing Program Analysts (LPAs) Jan Hoshida and Erwin Tjhia met with Program Coordinator, Jessica Galindo, and Program Developer, Nick Ebling for the purpose of an unannounced annual inspection. LPAs observed there were no school aged children present during the inpsection. Facility days and hours of operation are Monday through Friday from 7:00 AM to 6.00 PM. Facility provides a PM snack. Facility is on Paso Verde Elementary School campus and operates in portables W1 and W2. Facility is also licensed in classrooms A6, B8, C4, and the school's multipurpose room, but they are not currently using the additional spaces within the school. All staff present during today's inspection have a fingerprint clearance. All employee clearances are associates to 4th R - Crocker Riverside #340310500. LPAs toured the facility inside and out. LPAs observed that hazardous items (disinfectants, cleaning solutions, etc.) were inaccessible to children in care. LPAs observed the following items during today's inspection: First aid supplies, furniture, equipment, and access to drinking water. LPAs observed all required forms to be posted. Outdoor play area was toured, the play structure appeared to be in good repair, and there is sufficient cushioning (foam ground cover) under the play structure. Facility uses the grass area on the left side of the facility as an alternative outdoor play space, while school is in session. LPAs reviewed the sign in/out book and observed that the children are properly signed in/out. Report continues on 809-C

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin Tjhia	TELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

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: 4TH R - PASO VERDE	FACILITY NUMBER: 343623875
	VISIT DATE: 03/22/2022

NARRATIVE

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Children and staff files were reviewed. LPAs observed health screening reports with TB test and required MMR and TDAP vaccines. At least one staff member present today has current Pediatric CPR and First Aid. LPAs observed AB1207 mandated reporter training certificates for all staff. The staffs were reminded to renew the course every 2 years through www.mandatedreporterca.com website.

Facility Representative 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing 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.

Exit interview conducted and report was reviewed with the facility representative Jessica Galindo and Nick Ebling. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during the inspection.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Erwin Tjhia	TELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022

LIC809 (FAS) - (06/04)

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