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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393604765
Report Date: 12/17/2019
Date Signed: 12/18/2019 08:50:10 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: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: 15DATE:
12/17/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amber DorotinkskyTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Stacey Williams conducted a case management inspection at the facility listed above. LPA met with Lead Teacher Amber Dorotinksky. LPA observed (15) fifteen preschool children supervised by two staff during today's inspection.

Community Care Licensing received an incident involving child #1 (refer to confidential names list, LIC 811) injuring their finger with a stapler. LPA conducted interviews during today's inspection with the staff who was present when the injury occurred. Based on the information received, there was adequate supervision and the class was within ratio at the time of the incident. The staff interviewed explained they were sitting next to the child and the incident occurred when they turned their back to briefly look at another child. Protocol for art safety was explained to LPA. LPA was also informed there was no supplemental medical intervention needed when the child was taken to the doctor to exam the finger.

An exit interview was conducted with the lead teacher. Notice of site visit was provided and shall remain posted for 30 days. Appeal rights provided.

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
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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