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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393615675
Report Date: 04/28/2022
Date Signed: 05/11/2022 09:41:48 AM


Document Has Been Signed on 05/11/2022 09:41 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/29/2022 08:27 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

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This is an amended report.
On Thursday April 28, 2022 at 09:25 am, Licensing Program Analyst (LPA) Elvira Sierra met with Site Supervisor, Diana Flood for the purpose of an unannounced annual inspection. Census included nine preschool children supervised by three staff members. Facility is operating within the capacity and in compliance with staff child ratio on this day. Facility operates M-F, during the school calendar year, between 8 am to 11:30 am and from 12 am to 3:30 pm in the Maxine Hong Kingston Elementary school grounds in classroom # 1. Site Supervisor stated due to COVID-19 facility has temporary changed hours of operation; Currently facility operates M-F, between 08:00 am to 11:00 am and 12:00 pm to 03:00 pm.
LPA inspected all activity and classroom spaces, restrooms, food service, and outdoor play areas for Health and Safety hazards. All mandatory postings, are posted at the main entrance of the classroom. Classroom is adequately ventilated. The floors appeared clean throughout the facility. Classroom has age appropriate toys and equipment that are in good repair. There are cubbies for children belongings inside the classroom. Restroom in the classroom is maintained clean, in good repair and with adequate supplies. Staff use a separate restroom. Cleaning products and Toxins are maintained inaccessible to children. First Aid Kit and medications are appropriately stored and inaccessible to children. The isolation area for an ill child is in the office area. LPA observed at least one functional smoke/carbon monoxide detector and a fully charged 2A:10BC fire extinguisher. Facility has a working telephone at the site. Site Supervisor stated there are no poisons, or firearms on the premises. No bodies of water were observed. Outdoor space area was inspected. Facility offer drinking water by using igloo coolers and disposable cups. Facility provides am breakfast and pm lunch. Meals are prepared inside the school cafeteria. Menus are posted, updated and available for public view and also in the facility's website.

At 11:00 am three staff and nine children's files were reviewed. All staff currently employed with the center have criminal record clearances through the Stockton Unified School District. At least one staff member present today has current Pediatric CPR and First Aid certification. LPA reviewed the sign/in-sign/out sheets. Last Emergency Drill was conducted on 03/30/22 and is properly logged.

Report continues on subsequent page 809C---

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022
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: MAXINE HONG KINGSTON ELEMENTARY
FACILITY NUMBER: 393615675
VISIT DATE: 04/28/2022
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Site Supervisor 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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication 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.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/process.

A Notice of Site Visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Notice of Site Visit was posted by LPA. Exit interview conducted and report was reviewed with the Site Supervisor, Diana Flood.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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