393604765-1-9-2020-53-CC-SWIS-BKNU44-20200109141432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 393604765
Report Date: 01/09/2020
Date Signed: 01/09/2020 02:14:35 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 CENTER		FACILITY NUMBER:	393604765
ADMINISTRATOR:	RHOADES, MARTI		FACILITY TYPE:	840
ADDRESS:	1750 KAVANAGH STREET		TELEPHONE:	(209) 832-8799
CITY:	TRACY	STATE: CA	ZIP CODE:	95376
CAPACITY:	70	CENSUS: 16	DATE:	01/09/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Janet Shaffer		TIME COMPLETED:	02:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Stacey Williams conducted a case management inspection at the facility listed above. LPA met with Site Supervisor, Janet Shaffer,. LPA observed (16) sixteen preschool children supervised by two staff during today's inspection.

Community Care Licensing received an incident involving child #1(c1) (refer to confidential names list, LIC 811) injuring their hair line from a clothes pin. LPA conducted interviews during today's inspection with the staff who were 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 initially sitting in close proximity to c1 when a parent came into the classroom and requested copies of a document. Staff went to assist the parent and in the interim c1 was struck by a clothes pin from another child. The injury was observed and child #1's parent was notified. C1 was taken to the doctor by his parent where it was determined that no further medical attention was needed.

Staff reassessed the layout of the classroom and has since removed the hanging clothes pin from the walls a safety precaution .

An exit interview was conducted. Appeal rights printed and notice of site visit was posted.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey Williams	TELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020

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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