393605420-4-14-2023-53-CC-ESIA-CQVQBP-20230414120152

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 393605420
Report Date: 04/14/2023
Date Signed: 04/14/2023 12:02:03 PM

Document Has Been Signed on 04/14/2023 12:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME:	CREEKSIDE STATE PRESCHOOL		FACILITY NUMBER:	393605420
ADMINISTRATOR:	NGUYEN,NHUNG		FACILITY TYPE:	850
ADDRESS:	2515 ESTATE DRIVE, PORTABLE B		TELEPHONE:	(209) 331-7252
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95209
CAPACITY:	45	CENSUS: 25	DATE:	04/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Nhung Nguyen		TIME COMPLETED:	12:20 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 04/14/23. Licensing Program Analyst (LPA) Elvira Sierra met with facility representative, Nhung Nguyen for the purpose of an unannounced annual inspection. Representative was reminded never to exceed the conditions, limitations, and capacity specified on the license. The facility operates in portables #29 and # 43 inside the Creekside Elementary School campus. The program conducts part-time sessions 8-11 a.m. in Room 29 (state preschool classroom) and full-day sessions (8 am to 2 pm) in portable # 43 (Head Start classroom). Facility follows Lodi Unified School District calendar. A health and safety inspection was conducted in all areas accessible to children and the following was observed; LPA observed all required forms posted on both classrooms including the facility license, emergency disaster plan and seat belt law. Age appropriate toy and reading material were observed. Toxic and hazardous items are inaccessible to children. Furniture and equipment were observed to be in good repair. Facility has a fire extinguisher that meets the minimum requirements and operating smoke and a carbon monoxide detectors. Facility provides breakfast/lunch and menus were posted. Drinking water was readily available to children both indoors and outdoors. Emergency supplies are available and maintained. First Aid Kit is properly maintained and kept inaccessible to children. Per facility representative no children enrolled required any medication. Playground equipment was observed to be in good condition. Emergency Drills are conducted monthly and are properly logged. Sign in/sign out sheets are maintained. LPA reviewed 5 children's files and files of the staff that were present. All the files were observed to be complete. Staff have criminal record clearance through the school district. At least one staff member has a current CPR/First Aid Certificate. Report continues on subsequent page 809C--

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: CREEKSIDE STATE PRESCHOOL	FACILITY NUMBER: 393605420
	VISIT DATE: 04/14/2023

NARRATIVE

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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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulations and Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, a Plan for Providing 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. This Report and Appeal of Rights were provided and reviewed with the facility representative, Nhung Nguyen. Notice of Site Visit posted and must remain posted for 30 days.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/14/2023 12:02 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: CREEKSIDE STATE PRESCHOOL	FACILITY NUMBER: 393605420
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238.2(d)(2)

Outdoor Activity Space

(d) The surface of the outdoor activity space shall be maintained: (2) Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation facility did not comply with the section cited above by; LPA observe a hole in the playground which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/14/2023
	Plan of Correction
1 2 3 4

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: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira Sierra	TELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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