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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390300413
Report Date: 12/13/2022
Date Signed: 12/13/2022 03:09:28 PM


Document Has Been Signed on 12/13/2022 03:09 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:LODI DAY NURSERY SCHOOLFACILITY NUMBER:
390300413
ADMINISTRATOR:RACHAEL KULLINGFACILITY TYPE:
850
ADDRESS:760 SOUTH HAM LANETELEPHONE:
(209) 334-6884
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:135CENSUS: 41DATE:
12/13/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Racheal KullingTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst Carla Polanco (LPA1) and Licensing Program Analyst Katy Maestas (LPA2) conducted a Case Management inspection on 12/13/2022. LPA arrived at the facility and was met by the Director Racheal Kulling (D1). LPAs disclosed the purpose of the inspection and was granted entrance into the facility. LPAs observed 41 preschool-aged children being supervised by 5 adults. LPA1 accessed Guardian and ensured that all required adults were background cleared.
LPA2 observed a teacher step outside classroom #3, leaving 7 preschool-aged children in the classroom, since 1 child was using the restroom down the hall way. LPA2 observed that the teacher was not within proximity to the child in the restroom nor was she in full line-of sight of the children in the classroom.
Based on LPA2's observations, a Type-A citation was issued on a subsequent 809-D page. D1 understands that all parents or authorized representatives currently enrolled, and who enroll for up to 1 year, are required to sign the LIC 9224. The LIC 9224 form is to be kept in the child's file and available for the Department's review.
An exit interview was conducted in which the report and Plan of Correction was reviewed with D1. LPA provided L1 with Appeal Rights. A Notice of Site Visit was posted by LPA and shall remain posted for 30 days. Failure to comply with posting requirements will result in an immediate civil penalty of $100.


SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Nola MaestasTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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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Document Has Been Signed on 12/13/2022 03:09 PM - It Cannot Be Edited

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: LODI DAY NURSERY SCHOOL
FACILITY NUMBER: 390300413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2022
Section Cited

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101229 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time,...
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 D1 will create a written statement for all staff members to aknowledge the new policy for bathroom use. The policy will include using classroom #1 for toileting as well as a back-up plan for contacting the office to take a child to the restroom. All staff will sign and date the statament.
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Supervision shall include visual observation.
This requirement was not met as evidenced by: LPA observing a teacher stepping outside the classroom leaving 7 children unsupervised by lack of visual observation and 1 child in the restroom down the hallway not within proximity.
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D1 understands that she is to email the statement and all staff signatures to LPA Maestas by 12/27/2022.

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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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Nola MaestasTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
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