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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393619966
Report Date: 02/06/2020
Date Signed: 02/06/2020 11:30:05 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:HOME CHURCH, THEFACILITY NUMBER:
393619966
ADMINISTRATOR:CRAIG, JEFFFACILITY TYPE:
850
ADDRESS:11451 N. WEST LANETELEPHONE:
(209) 339-7333
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY:24CENSUS: 11DATE:
02/06/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:May CooperTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Justin Denton met with Director May Cooper for the purpose of an unannounced annual random inspection. Director Cooper was reminded never to exceed the conditions, limitations and capacity specified on the license. Census included 11 preschool children supervised by 2 staff members who all have obtained a criminal record clearance through Community Care Licensing. Facility hours of operation are Monday through Friday from 8:00AM - 2:00PM or 5:00PM in case of emergency.

LPA toured all activity and classroom spaces, restrooms, and outdoor play areas. LPA observed medication stored in a child's backpack instead of centrally stored. Director stated there are no poisons, bodies of water or fire arms on the premises. Toxic and hazardous items are inaccessible to children. Furniture and equipment are in good condition. Playground equipment and surfaces are free of loose or sharp parts. The areas around or under climbing equipment are cushioned with padding to absorb the fall. Toileting facilities are in safe, sanitary and operating condition. The floors appeared clean throughout the facility. The facility does not prepare food on-site. Drinking water was readily available to children both indoors and outdoors. LPA observed full legal signatures while reviewing the sign in and sign out sheet.

Staff and children's records were reviewed. Each child's file reviewed contained an emergency card and a medical assessment. At least one staff member present today has current Pediatric CPR and First Aid certification, which expires on 07/29/2021.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2020
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 3
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: HOME CHURCH, THE
FACILITY NUMBER: 393619966
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2020
Section Cited

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Health-Related Services: All prescription and nonprescription medications shall be centrally stored in accordance with the requirements specified below (...) Medications shall be kept in a safe place inaccessible to children. This requirement was not met as evidenced by:
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LPA observed two epi-pens stored in a child's backpack on the floor of Room 105.
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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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: HOME CHURCH, THE
FACILITY NUMBER: 393619966
VISIT DATE: 02/06/2020
NARRATIVE
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An Exit Interview was conducted. A Notice of Site Visit was provided. Appeal rights were also provided. Licensee was encouraged to the visit the Departmental website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, provider information notices, regulations and legislation pertaining child care centers.

See next page for deficiency cited.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3