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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390316994
Report Date: 08/29/2019
Date Signed: 08/29/2019 02:51:49 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:ST. LUKE'S CATHOLIC PRESCHOOLFACILITY NUMBER:
390316994
ADMINISTRATOR:LAURA RODRIGUEZFACILITY TYPE:
850
ADDRESS:4005 N. SUTTER STREETTELEPHONE:
(209) 465-5368
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:72CENSUS: 37DATE:
08/29/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Laura Rodriguez, DirectorTIME COMPLETED:
03:10 PM
NARRATIVE
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During today's inspection Licensing Program Analysts (LPAs) Charlotte Baney and Chayntel Hunter met with Director, Laura Rodriguez to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 8/23/19. During today's visit the facility was toured. Present were 37 preschool children in care and 10 staff.

LPAs interviewed the Director, regarding the incident. LPAs reviewed and discussed this report with the Director.

The facility reported the UIR to Community Care Licensing within 24hrs. A written UIR was submitted within 7 days, describing the specifics of the incident.

The following Title 22 Deficiency is being cited on the subsequent 809-D page. Upon receipt of Type A citations, licensee shall post and provide copies of the LIC 809-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 809-D in each child's file. Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2019
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: ST. LUKE'S CATHOLIC PRESCHOOL
FACILITY NUMBER: 390316994
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2019
Section Cited

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CCR 101229(a)(1) No child(ren) shall be left without the supervision of a teacher at any time. Supervision shall include visual observation. This requirement was not met as evidenced by: a child was left unsupervised outside on the play yard. This
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is an immediate health and safety risk for children. LPAs learned on 8/23/19 from the Director that a child was left in a playhouse for 2-3mins on 8/22/19. It was brought to the Director's attention, the next day, by the parent who had found and returned the child to staff.
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call checks upon entering and exiting the classrooms. Director is going to send a copy of the attendance roster and the minutes from the meeting, to LPA Baney, by POC date.

charlotte.baney@dss.ca.gov

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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: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2019
LIC809 (FAS) - (06/04)
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