390317580-11-16-2021-53-CC-SWIS-C8LUDA-20211109142913

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 390317580
Report Date: 11/09/2021
Date Signed: 11/16/2021 09:40:09 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:	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: 13	DATE:	11/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Sokanha Bartholomy		TIME COMPLETED:	02:40 PM

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On November 9, 2021 Licensing Program Analyst (LPA) Stacey Williams met with Facility Representative for the purpose of an unannounced required annual inspection. Facility operates on the campus of Elmwood Elementary. Program hours are Monday through Friday 8:00AM-2:00PM. The program operates a full day program in portable C7. Upon arrival, LPAs observed (13) thirteen children supervised by three staff. Criminal record clearances are done through Stockton Unified School District.

LPA conducted a health and safety inspection for all areas accessible to children. Staff stated there are no poisons on the premises. Toxic and hazardous items are inaccessible to children. Furniture and equipment are in good condition. LPA observed a functional smoke/carbon monoxide detector and a fully charged 2A :10BC fire extinguisher. The floors appeared clean throughout the facility. Outdoor play area is free from dangerous conditions and playground equipment is securely anchored to the ground. Facility uses bark under the play equipment to absorb falls. Program provides breakfast and lunch. Menus were posted by the main entrance of the facility. Facility offers drinking water by using a water dispenser and disposable cups. Sign in/out sheet were reviewed.

Ten child files were reviewed. Each child’s file contained an emergency card, and a medical assessment. Files for staff who were present at the facility were reviewed. Staff have a criminal record clearance, health screening report, mandated reporter training, immunization records, and documentation of their educational background, training, and/or experience. LPA reviewed the Department's inspection authority and discussed with staff any changes that may occur regarding Director/Site Supervisor or an employee acting in the director's absence must be reported to department within 10 working days.

Report continues on 809-C

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey Williams	TELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

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: ELMWOOD ELEMENTARY SCHOOL	FACILITY NUMBER: 390317580
	VISIT DATE: 11/09/2021

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Per facility representative there are no children that require medication. Facility has an Incidental Medial Service Plan on file. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

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.

Exit interview conducted and report was reviewed with the Facility Representative, Sokanha Bartholomy. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey Williams	TELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

LIC809 (FAS) - (06/04)

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