475407973-2-28-2022-13-CC-JSNW-CC3T2D-20220228132034

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 475407973
Report Date: 02/28/2022
Date Signed: 02/28/2022 01:21:31 PM

Document Has Been Signed on 02/28/2022 01:21 PM - 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	SISKIYOU EARLY HEAD START		FACILITY NUMBER:	475407973
ADMINISTRATOR:	WALTERS, KERMITH		FACILITY TYPE:	850
ADDRESS:	1 CHILDS WAY		TELEPHONE:	(530) 842-8493
CITY:	YREKA	STATE: CA	ZIP CODE:	96097
CAPACITY:	30	CENSUS: 7	DATE:	02/28/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Chez Giertz		TIME COMPLETED:	01:45 PM

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Facility representative was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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. The is a public agency requiring background clearance as a condition of employment. There are multiple agencies licensed at this address.

This is a combination facility with an infant license for 8 in building D with its own play yard. Today I am licensing Building B1, B2 and Building E. The facility plans to have toddlers in building B (1&2) and preschoolers in building E. The Toddlers will be kept separate from the preschoolers and they will be separately supervised and will not use the play yard at the same times. There are 5 toilets, more than 5 skinks and staff bathrooms.

LPA reviewed with r facility representative the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at (continued)

SUPERVISOR'S NAME: Erin Virrueta	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaime Snow	TELEPHONE: (530)215-6132
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: SISKIYOU EARLY HEAD START	FACILITY NUMBER: 475407973
	VISIT DATE: 02/28/2022

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https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. Exit interview conducted and report was reviewed with the facility representative, Chez Giertz.

The following is required before issuing the license:

____ Shared playground schedule

____ Incidental Medical Plan (IMS)
____ Board Resolution authorizing application, naming the director and administrator ( Chez Giertz & Nicole Whitlow) or providing the date of the next meeting & a statement that it will be immediately sent to CCL).
____ Must have criminal record clearance and association to facility for the Director or Administrator or someone on the Board. Send transfer document with copy of photo ID if necessary.
____ Director information (listed below)
· LIC 503 (Health Screening) and TB clearance within 6 months of hire date
· Poof of immunization against Measles, Pertussis, and Influenza (Influenza -optional)
· LIC 508 (Criminal Record Statement)
· LIC 9096 Evaluation of Director Qualifications (also see Title 22; Section 101215.1
Child Care Center Directors Qualifications and Duties) include a copy of official
transcripts, site supervisor permit, credentials, verification of work experience, etc.
· Preventative Health Practices training (training completed prior to 2016 may require an additional component of Nutrition or Lead)
· LIC 500 (Personnel Report)
· LIC 610 (Emergency Disaster Plan)
· LPC 9108 Statement Acknowledging Requirement to Report Suspected Child Abuse
· Letter or Board Resolution from Licensee naming the new director (or providing the date of the next meeting & a statement that it will be immediately sent to CCL).
· Mandated Reporter Training (General and Child Care certificates)
· The file will be reviewed when the application is received, and additional information may be required.

SUPERVISOR'S NAME: Erin Virrueta	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaime Snow	TELEPHONE: (530)215-6132
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

LIC809 (FAS) - (06/04)

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