<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393620781
Report Date: 11/15/2019
Date Signed: 11/15/2019 03:34:13 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:CREATIVE CHILD CARE @ DON AVENUE CDCFACILITY NUMBER:
393620781
ADMINISTRATOR:EISON, DEBRAFACILITY TYPE:
850
ADDRESS:8121 DON AVENUETELEPHONE:
(209) 956-2686
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY:109CENSUS: 48DATE:
11/15/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mayra MadrigalTIME COMPLETED:
03:45 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
Licensing Program Analyst (LPA) Stacey Williams arrived at the above facility for the purpose of conducting a case management inspection. LPA met with Site Supervisor, Mayra Madrigal. LPA observed (48) forty eight children supervised by (8) eight staff. It was revealed through follow up investigation on an incident report submitted to Community Care Licensing that a child was hurt while in care and sustained an injury to their ear from being cut with scissors from another child.

Based on interviews and information received, title 22 personal rights deficiency will be cited on subsequent page, LIC 809D.

Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.

This report was reviewed and discussed with the Site Supervisor. A notice of site visit and appeal rights were provided.



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

DATE: 11/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019
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 2
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: CREATIVE CHILD CARE @ DON AVENUE CDC
FACILITY NUMBER: 393620781
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2019
Section Cited

1
2
3
4
5
6
7
Personal Rights:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by: Child sustained an injury to their ear from being cut with scissors by another child in the classroom. Two teachers were present,
8
9
10
11
12
13
14
however evidence submitted indicated the lasseration was not superficial scrape as initially reported. Flesh was cut on the inner ear and outer ear lobe which caused excessive bleeding. This is an immediate health and safety risk to children in care.
8
9
10
11
12
13
14
of the revised group time policy. Director will submit notification given to parents by POC date of 11/18/19 as well as proof of supply order for new scissors to CCL. Staff will be informed of the new small group time policy by POC date.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Maria MayorgaTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2