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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500364
Report Date: 11/19/2021
Date Signed: 11/19/2021 10:56:12 AM

Document Has Been Signed on 11/19/2021 10:56 AM - 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:CITY OF DAVID ACADEMYFACILITY NUMBER:
394500364
ADMINISTRATOR:KHADIJAH WARRENFACILITY TYPE:
840
ADDRESS:2350 EAST MARKET STREETTELEPHONE:
(209) 641-9336
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 40TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
11/19/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Pamela Pettis-HoustonTIME COMPLETED:
11:30 PM
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Application Specialist (AS) Alecia Sifuentes met with Applicant, Pamela Pettis-Houston for the purpose of an announced pre-licensing inspection. Applicant requests a school-age license to serve 40 school-age children from kindergarten and above. The program will operate Monday through Friday from 7:00 a.m. to 6:00 p.m. The fire clearance was granted and received on 10/5/2021.

Applicant acknowledges that the following documents must be posted at all times: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, car seat poster, menus, and daily schedule. AS discussed the forms that must be in each child's and each staff member's file. AS provided LIC311A, Effects of Lead Exposure brochure, and Healthy Schools Act survey. The facility will be providing morning and afternoon snack during the school year and snacks during holidays and summer.

INDOOR ACTIVITY SPACE:
There are six school-age classrooms. AS observed a sufficient amount of equipment, tables, chairs, and hooks. There is a first aid kit located in the downstairs classroom. Medications will be stored in the kitchen cabinet. AS observed cleaning disinfectants are appropriately stored and inaccessible to children. Applicant stated there are no poisons or firearms on the premises. AS observed a water dispenser and cups in the classroom. AS observed a functional carbon monoxide detector in the classrooms. AS observed a sign-in/sign-out binder.

Report continues on 809-C.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2021
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: CITY OF DAVID ACADEMY
FACILITY NUMBER: 394500364
VISIT DATE: 11/19/2021
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AS measured six classrooms. The total classroom space contains a total of 2,651 square feet, which will accommodate Applicant's request for 40 school-age children. There are 4 toilets and 4 sinks for the children, and a separate private restroom for the staff. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the computer room and will use the staff restroom, if necessary.

OUTDOOR ACTIVITY SPACE:
There is one school-age outdoor area on the property. The outdoor play area is fenced with a wooden and chain link fence that is at least four feet tall. Applicant will be installing temporary fencing due to part of the playground needing additional fencing installed in order to be fully fenced. AS observed a sufficient amount of equipment and toys. There are no bodies of water on the premises. There are shaded areas supplied overhangs.

AS measured the outdoor activity space. The outdoor play area contains a total of 2,169 square feet, which will only accommodate 28 school-age children. Applicant has requested an Insufficient outdoor Space Waiver and provided AS will outdoor scheduled times. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

This facility does not provide Incidental Medical Services at this time– IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A Plan of Operation that includes 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

Report continues on 809-C.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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: CITY OF DAVID ACADEMY
FACILITY NUMBER: 394500364
VISIT DATE: 11/19/2021
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AS discussed the following: supervision; personal rights; inspection authority; reporting requirements; staff to children ratios and capacity; staff qualifications; and maintaining buildings and grounds. AS discussed with Applicant any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

This facility evaluation report was reviewed and discussed with Applicant. Applicant was encouraged to the visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to child care centers.

The following items are required before a license will be issued:
1. Remaining documents listed on LIC184.
2. Proof of temporary playground fencing.
3. Final file review by Licensing Program Manager (LPM) Justin Denton.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
LIC809 (FAS) - (06/04)
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