390317580-3-22-2023-53-CC-SWIS-CQ6TU9-20230322150158

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 390317580
Report Date: 03/22/2023
Date Signed: 03/22/2023 03:02:05 PM

Document Has Been Signed on 03/22/2023 03:02 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:	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: 12	DATE:	03/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Safiya Price		TIME COMPLETED:	03:15 PM

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On March 22, 2023, Licensing Program Analyst (LPA) Stacey Williams met with Facility Representative for the purpose of an unannounced required year inspection. Program operation hours are Monday through Friday 8:15AM-2:15PM. Upon arrival, LPA observed twelve (12) children supervised by two 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 play equipment to absorb falls. Program provides breakfast and lunch. Meals are provided through the school district. Menus were posted in the entry of the facility. Facility utilizes drinking water from the classroom sink faucet with disposable cups. Water is accessible both indoor and outdoors. There is one water fountain on the outside play structure that is currently inoperable. LPA discussed lead testing requirements for accessible water with the facility representative. Facility Representative stated the water sources were tested in February 2023. There is no additional information provided at this time for the lead testing results. Sign in/out sheets were reviewed. Each child has individual clipboards for sign in/out sheets.

Child files were reviewed. Each child’s file included information pertaining to their authorized representative, consent for medical treatment, immunization records, and a medical assessment form. Files for staff who were present at the facility were reviewed. Staff have a criminal record clearance through Stockton Unified school district. Mandated Reporter training completion certificates are from Keenan and Associates. Health screening report, immunization records, and documentation of their educational background, training, and/or experience was verified in files. CPR/ First Aid certification was verified for staff present. Lead Teacher has a CPR/First Aid expiration date of 9/2024.

Report continues on LIC 809-C

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey Williams	TELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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: 03/22/2023

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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.

Per facility representative there are children that have IMS service plan on file. 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.

No Title 22 deficiencies were observed during today’s inspection.

LPA reviewed report with the Facility Representative, Safiya Price and provided copies of the report along with Appeal Rights.

A notice of site visit was provided and posted by LPA Williams and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey Williams	TELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

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