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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393604765
Report Date: 06/19/2019
Date Signed: 06/19/2019 01:46:14 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:MELVILLE S. JACOBSON CHILD DEVELOPMENT CENTERFACILITY NUMBER:
393604765
ADMINISTRATOR:RHOADES, MARTIFACILITY TYPE:
840
ADDRESS:1750 KAVANAGH STREETTELEPHONE:
(209) 832-8799
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:70CENSUS: 50DATE:
06/19/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Marti RhoadesTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst, Mary Ponce met with director Marti Rhoads for an unannounced annual inspection. LPA toured the facility including all activity/classroom areas, food service area, restrooms and outdoor play areas. LPA observed care and supervision of children. There were 4 staff supervising 50 children. LPA observed that all medications were in a central location and out of reach from children in care. LPA observed that the two bathrooms in the school age classroom had working toilets and sinks. While inspecting the bathroom, LPA observed a box of contact solution within reach of children which is an immediate risk to the health and safety of children in care. LPA removed the Contact solution and director stated that she will ensure it is not left in the environment. LPA observed readily accessible water inside. Director stated that drinking water is brought out to for the children during outside play. LPA also inspected the food preparation area. LPA observed food being served without proper coverage to prevent flies from landing on the food or other contamination which is a possible risk to the health and safety of the children in care. LPA observed menus posted in the parent area.

LPA reviewed the sign/in-sign/out sheet as required for school age component, and children are being signed out with full signature from their legal guardian. and at least one staff member present today has current CPR/ First Aid that expires on 6/24/19. LPA advised director to ensure that staff are up to date with their CPR/ First aid Training. All staff currently employed with the facility has a criminal record clearance, poisons are locked and there are no firearms or bodies of water on the property.

LPA reviewed 6 children's files and observed each one had an Emergency Card, Consent for Medical Treatment, Personal Rights, and Parents Rights forms filled out and signed by
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
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 4
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: MELVILLE S. JACOBSON CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 393604765
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/20/2019
Section Cited
CCR
101238(g)
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Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.
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POC: LPA immediately removed the Contact solution and director placed it in the office; therefore this deficiency has been cleared.
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This regulation was not met as evidence of Eye Contact Solution being within reach of children in care inside the bathroom cabinet which did not have a lock on it.
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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 MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: MELVILLE S. JACOBSON CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 393604765
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2019
Section Cited
CCR
101227(a)(19)
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All food shall be protected against contamination. Contaminated food shall be discarded immediately.
This regulation was not met as evidence by; the food being
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POC: Director will conduct a meeting with staff to discuss proper food handeling and how to prevent contamination. Director stated she will be purchasing plate covers to ensure they remain covered.
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served during lunch was not covered.
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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 MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: MELVILLE S. JACOBSON CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 393604765
VISIT DATE: 06/19/2019
NARRATIVE
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their legal guardian. LPA reviewed 4 staff files and observed that all staff have proper immunization for Measles, pertussis, and either the influenza shot or the declination of the flu shot.

LPA reviewed Department’s inspection authority and discussed with designee any changes that may occur regarding the Director or an employee acting in director's absence must be reported to department within 10 working days.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised the licensee of their responsibility to stay current in regards to new regulations.

This facility plans to provide IMS, LPA advised the licensee that IMS information can be found in the Evaluator Manual/Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and the Medication Regulations 101226. A Plan of Operation that includes IMS must be submitted to LPA. LPA provided the following information regarding ADA: US Department of Justice (USDOJ), 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: www.ada.gov/childqanda


Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, licensee shall post and provide copies of the LIC 809D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 809D in each child's file.


Appeal rights and Notice of Site Visit were provided. Notice of Site visit must remain posted for 30 days.
SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Mary PonceTELEPHONE: (916) 216-7823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4