390317580-1-8-2020-53-CC-SWIS-BKMVL2-20200108153112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 390317580
Report Date: 01/08/2020
Date Signed: 01/08/2020 03:31:20 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:	ELMWOOD ELEMENTARY SCHOOL		FACILITY NUMBER:	390317580
ADMINISTRATOR:	SEMILLO, JOHN		FACILITY TYPE:	850
ADDRESS:	840 S. CARDINAL		TELEPHONE:	(209) 933-7180
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95215
CAPACITY:	24	CENSUS: 16	DATE:	01/08/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	Sokanah Bartholomy		TIME COMPLETED:	03:41 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

Licensing Program Analyst (LPA) Stacey Williams met with Sokanha Bartholomy, Lead Teacher for the purpose of an unannounced annual random inspection. LPA observed (16) sixteen children supervised by 2 staff. Criminal record clearances are conducted through the school district.

Program hours are Monday through Friday 7:40AM-1:40PM. The program operates a full day program in portable C7 on the campus of Elmwood Elementary School. Program provides breakfast and lunch. LPA viewed the facility menu posted on the bulletin board in the classroom.

LPA toured the facility inside and out. All cleaning supplies and hazardous items are stored in a locked cabinet inaccessible to children. Outdoor activity space and equipment was in good repair. Bark is being used as cushioning around the climbing equipment and playground structure. Bark did not appear to be a sufficient level to absorb a fall. There are areas of the playground structure that have uneven bark which leaves dips in the corners of the perimeter of the structure. While touring the outdoor space, LPA observed a medium sized water drain pipe protruding from the ground of the grass play area. Lead teacher reported the area is surrounded by cones during classroom hours and a work order request has been submitted to repair the area. Drinking water was readily available. The classroom has a water fountain and water jug is utilized when the children are outside.

Restrooms were sanitary and in operating condition. Storage containers for solid waste had lids. Fire drills are conducted and documented. Carbon Monoxide and smoke detectors were present and operable.

LPA reviewed a random sample of children files during the inspection. LPA observed files included information pertaining to authorized representative, consent for medical treatment and a medical assessment form.

LPA reviewed a random sample of staff records. LPA observed current CPR/First Aid certification for staff present during today’s inspection (expiration date, 9/2020) . Immunization records, mandated reporter training completion certificate and documentation of educational background, training, and/or experience was verified in staff files.

Report Continues on 809-C

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey Williams	TELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020

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 3

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: ELMWOOD ELEMENTARY SCHOOL	FACILITY NUMBER: 390317580
	VISIT DATE: 01/08/2020

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
26
27
28
29
30
31
32

Incidental Medical Services (IMS) policy was discussed. The facility currently has children utilizing incidental medical services. 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.

Title 22 deficiencies were observed during today’s inspection and will cited on subsequent page, LIC 809D.

This facility evaluation report was reviewed and discussed with Lead Teacher, Sokanha Bartholomy. The implementation of AB 2370, lead exposure was discussed. Lead Teacher was encouraged to the visit the department’s website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to child care centers.

Exit interview conducted. A notice of site visit was provided and should remain posted for a period of 30 days for parental review. Appeal Rights provided.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey Williams	TELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: ELMWOOD ELEMENTARY SCHOOL	FACILITY NUMBER: 390317580
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/08/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/07/2020 Section Cited	1 2 3 4 5 6 7	The surface of the outdoor activity space shall be maintained:(2) Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: LPA toured the outdoor play area during today's inspection and observed a medium sized water drain pipe protruding from the ground of the grass play area. This is a potential risk to the health and safety of children in care.	8 9 10 11 12 13 14	Work order invoice will be submitted to LPA Williams by POC date- 2/7/2020. LPA will conduct a follow up POC inspection.
Type B 02/07/2020 Section Cited	1 2 3 4 5 6 7	The surface of the outdoor activity space shall be maintained: This requirement was not met as evidenced by: LPA toured the outdoor play area during today's inspection and observed bark did not appear to be a sufficient level to absorb a fall.
	8 9 10 11 12 13 14	There are areas of the playground structure have uneven bark which leaves dips in the corners of the perimeter of the structure. This is a potential risk to the health and safety of children in care.	8 9 10 11 12 13 14

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 Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey Williams	TELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020

LIC809 (FAS) - (06/04)

Page: 3 of 3