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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 475401924
Report Date: 11/14/2019
Date Signed: 11/14/2019 12:20:06 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:MONTAGUE ELEMENTARY SCHOOLFACILITY NUMBER:
475401924
ADMINISTRATOR:FRALEY, VICKIFACILITY TYPE:
850
ADDRESS:430 EAST PRATHER STREETTELEPHONE:
(530) 459-1466
CITY:MONTAGUESTATE: CAZIP CODE:
96064
CAPACITY:22CENSUS: 10DATE:
11/14/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Vicki FraleyTIME COMPLETED:
01:00 PM
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An Annual inspection was made to the facility by Licensing Program Analyst (LPA), Snow. The facility file was reviewed prior to this inspection. A review of the personnel report on 11/1/19 indicates that no facility staff is associated to the facility. The staff is printed and cleared through the School as a condition of employment. This program is operated by the school district and is a Title 5 funded program.

The facility’s operating hours are 8:00 am - Noon Monday – Friday. The facility was toured inside and outside, and the floor and yard plan submitted by the licensee were verified. The items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children. Poisons are locked in the janitors’ closet. The facility was free of flies, insects and rodents. The toys, floors, desks and other equipment and surfaces were clean, toxic free, safe and in good condition. There is uncontaminated drinking water available to children both indoor drinking fountain and outdoors Dixie cups. The children’s bathrooms were in safe and sanitary condition. A current menu was posted in the entryway. Food prep areas are clean. Food is properly stored and free of contamination. Garbage cans containing solid waste have tight fitting lids. The playground was free of hazards. The playground equipment and surface areas were in safe condition.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
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 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: MONTAGUE ELEMENTARY SCHOOL
FACILITY NUMBER: 475401924
VISIT DATE: 11/14/2019
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 There is wood chip cushioning underneath climbing structures and/or play equipment to absorb falls. There were no bodies of water observed. The Lead teacher, Vickey Fraley stated no weapons are stored on site and none were observed. During today's inspection, staffing ratios were being met and there were 10 children were being supervised by 2 teachers. The facility was operating within the licensed capacity. At least one staff member present during the visit (S#) possessed current CPR and First Aid certifications. Four children’s records were reviewed at 11:45 am, and contained identification forms with authorized representative information, as well as medical assessments. Two staff records were reviewed at noon, and contained health screening forms. The sign in/out procedure was reviewed and in compliance. This facility is not providing Incidental Medical Services (IMS) to children. The Department’s IMS policy was discussed with the Lead teacher. (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: www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices brochure, were reviewed and discussed with the Lead Teacher. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: MONTAGUE ELEMENTARY SCHOOL
FACILITY NUMBER: 475401924
VISIT DATE: 11/14/2019
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There were no Title 22 deficiencies cited during today's inspection.
The LPA requested the following to be completed for the Director, Matthew Dustin, within the next 30 days (by 12/14/19).
• LIC 215 Applicant Information
• LIC 503 (Health Screening) and TB clearance
• LIC 508 (Criminal Record Statement)
• LIC 9096 Evaluation of Director Qualifications /Permit
• Current pediatric CPR, First Aid, and Preventative Health Practices training
• Certificate for Child Care Orientation III (record keeping)
• A board resolution letter naming Dustin Matthew as Director
• LIC 309 Administrative Organization
• Must have criminal record clearance and association to facility. Send transfer document with copy of photo ID if necessary
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Jaime SnowTELEPHONE: (530) 215-6132
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3