390317630-11-2-2023-53-CC-CPRA-CX7QY9-20231102123445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 390317630
Report Date: 11/02/2023
Date Signed: 11/02/2023 12:34:52 PM

Document Has Been Signed on 11/02/2023 12:34 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	HAZELTON ELEMENTARY SCHOOL		FACILITY NUMBER:	390317630
ADMINISTRATOR:	RAY SCHRAM		FACILITY TYPE:	850
ADDRESS:	535 W. JEFFERSON		TELEPHONE:	(209) 933-7210
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY:	46	CENSUS: 25	DATE:	11/02/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Lead Teacher Taunia Scroggins		TIME COMPLETED:	01:15 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	On 11/2/23, Licensing Program Analyst Carla Polanco Rivera (LPA), met with Lead Teacher Taunia Scroggins in classroom G-3, and Lead Teacher Erica Richard in classroom G-7; both classes share one room that is partitioned by a wall. This facility is licensed for classroom G-7. Today's visit was for the purpose of an unannounced annual inspection. During today's inspection there were 12 children present in G-7 and 13 children in G-3. Facility days and hours of operation are Monday- Friday, 8:00 AM-11 AM. LPA reviewed care and supervision of children, staffing ratios and first aid supplies, furniture, equipment, fire drills and drinking water. There are adequate toys and equipment available for children. Observations and interviews with staff revealed that the playground, used by the preschool classrooms, is lacking a surface which adequately absorbs falls. Additionally, the surface is not fully affixed to the ground which poses a tripping hazard; visible gaps in the cushioning were also present. LPA observed all required forms to be posted. Food is provided by the school district. Menus were posted and drinking water was readily available to children. LPA reviewed the sign in/out clip boards in classrooms and observed that children are properly signed in. Report Continued on LIC809-C.............

SUPERVISOR'S NAME: Karyn Guerra	TELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Carla Polanco Rivera	TELEPHONE: (916) 212-0752
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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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Document Has Been Signed on 11/02/2023 12:34 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HAZELTON ELEMENTARY SCHOOL	FACILITY NUMBER: 390317630
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238.2(d)

Outdoor Activity Space

(d) The surface of the outdoor activity space shall be maintained: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	The unsafe condition of the preschool playground surface poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	The facility will repair or replace the surface on the preeschool playground by 2/29/24. Until such time, the facilty will use traffic cones to block off the areas on the padded playground floor that are in unsafe conditions to children. LPA will conduct an unannounced POC visit to clear the deficiency.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Karyn Guerra	TELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Carla Polanco Rivera	TELEPHONE: (916) 212-0752
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HAZELTON ELEMENTARY SCHOOL	FACILITY NUMBER: 390317630
	VISIT DATE: 11/02/2023

NARRATIVE

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Staff and children's records were reviewed in classrooms. Files reviewed contained an emergency card and consent for medical treatment. At least one staff member present in each of the classrooms has current Pediatric CPR and First Aid certification, Teacher Scroggins (Exp. 06/2024 ) & Teacher Richard (Exp.07/2025 ). All staff are currently employed through the District and have a criminal record clearance, mandated reporter certificates, and documentation of the educational background, training, and/or experience. LPA observed health screening reports with TB test and required MMR and TDAP vaccines for staff members. Staff are required to renew Mandated Reporter training every 2 years, training is available through the www.mandatedreporterca.com website.

Meals are provided by the SUSD school district and served to the children in the classroom.

LPA reviewed storage of medication, and child personnel records. 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

An exit interview was conducted and the report was reviewed with Lead Teacher Taunia Scroggins. A notice of site visit was posted by LPA in both classrooms and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

LPA informed Teacher Scroggins, that this report dated 11/2/23, documents a Type-B deficiency, which was cited on a subsequent 809-D page.

SUPERVISOR'S NAME: Karyn Guerra	TELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Carla Polanco Rivera	TELEPHONE: (916) 212-0752
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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