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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390319950
Report Date: 04/20/2023
Date Signed: 04/20/2023 01:29:21 PM


Document Has Been Signed on 04/20/2023 01:29 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 SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:MONTEZUMA SCHOOLFACILITY NUMBER:
390319950
ADMINISTRATOR:KELLER, DEBRAFACILITY TYPE:
850
ADDRESS:2843 FARMINGTONTELEPHONE:
(209) 933-7255
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY:48CENSUS: 14DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gabriela FloresTIME COMPLETED:
01:45 PM
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On April 20th, 2023, at 11:30 am, Licensing Program Analysts (LPAs), David Nguyen and Lauren Scott met with Facility Representative, Gabriela Flores to conduct an unannounced annual inspection. The purpose of unannounced annual inspection was explained. LPAs were granted for entry into the facility by Facility Representative.

The Head Start program in the portable is Monday - Friday, from 8:00am to 2:00pm they serve breakfast and lunch children, which is provided by the school district. The State Preschool located in room 4 serves breakfast to morning class and lunch to afternoon class.

LPA toured the inside and outside of the facility, including all activity/classroom areas, restrooms, and outdoor play areas. Outdoor play area was toured, the play structure appeared to be in good repair, and there is sufficient cushioning (woodchips) under the play structure.

LPA observed two toilets and two sinks for use by the children in the Head Start portable. LPA observed a separate staff bathroom which was inaccessible to the children. Cleaning supplies were stored in an upper locked cabinet. LPA observed children's toys were in good condition and in sufficient supply. LPA reviewed staffing ratios, first aid supplies, furniture, equipment, fire drills and drinking water. LPA observed functioning carbon monoxide and smoke alarms. LPA observed that all of the required forms were posted including a license, meal/snack menu that meets regulation, parents' rights' poster, emergency care and disaster plan and seat belt law.

Report continues on 809-C.
SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: David NguyenTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2023
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
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: MONTEZUMA SCHOOL
FACILITY NUMBER: 390319950
VISIT DATE: 04/20/2023
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LPA reviewed health related services, including first aid supplies, furniture, equipment, drinking water and food service provisions. LPA reviewed the sign/in-sign/out sheet, children's records, and personnel records. All staff present during today's inspection have a fingerprint clearance through the Stockton Unified School District. 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.

LPA observed that health screening reports and proof of immunization are centrally stored in an off-site location. At least one staff member present during today's inspection has current Pediatric CPR and First Aid. LPA observed training certificate for approved third party mandated reporter training resource for all staff. LPA observed AB1207 Mandated Reporter training certificates for all staff. The Teacher was reminded to renew the course every 2 years through www.mandatedreporterca.com website.

This facility provides Incidental Medical Services (IMS). LPA reviewed storage of medications and equipment/supplies, and reviewed children’s personnel, and administrative 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

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/inspection-process.
Exit interview conducted and report was reviewed with the facility representative. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
In the areas that were evaluated, no deficiencies were cited during the inspection.
SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: David NguyenTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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