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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503600291
Report Date: 05/05/2022
Date Signed: 05/05/2022 03:06:52 PM


Document Has Been Signed on 05/05/2022 03:06 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, 1310 E. SHAW AVE,
FRESNO, CA 93710



FACILITY NAME:EMPIRE HEAD STARTFACILITY NUMBER:
503600291
ADMINISTRATOR:CENTENO, CONSUELOFACILITY TYPE:
850
ADDRESS:5201 FIRST STTELEPHONE:
(209) 527-9884
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:20CENSUS: 15DATE:
05/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Consuelo Centeno TIME COMPLETED:
03:15 PM
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On 05/05/22 Licensing Program Analyst (LPA) Araceli Gibson, conducted an unannounced annual inspection. LPA met with Site Supervisor Consuelo Centeno. This facility is located at the rear of Empire Elementary School Campus. Empire Head Start is one classroom with a census of 15 children present at today’s inspection. LPA Gibson toured the facility, both indoors and outdoors to inspect areas accessible to children. Empire Head Start runs a four hour program Monday through Friday from 8:00 AM to 12:00 PM and operate a regular school year schedule from August ending this year on May 27, 2022. Children are feed breakfast in the classroom with food brought in from the Empire Elementary School and lunch is provided in the school cafeteria.

There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible. No poisons were observed during the inspection.

Furniture and equipment are in good condition, free of sharp, loose or pointed parts. Playground equipment is in safe condition, however there is a large boarded playhouse structure that is pending removal per work order 03/09/22. The surface of the outdoor activity space is maintained in a safe condition and monitored for hazards. During today’s inspection LPA Gibson inspected the emergency exit leading to an outdoor space which was flooded and pooling behind the classroom. LPA addressed the issue with Site Supervisor and Maintenance regarding a repair. (see 809D for further). All toilets and handwashing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. All kitchen, food preparation and storage areas are clean, free of litter/rubbish and free of rodents/vermin. All food is protected against contamination and any contaminated food is discarded immediately. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors. Areas around high climbing equipment, swings and slides have cushioning material to absorb falls. The facility is free of flies, insects and rodents. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review have received a criminal record clearance or exemption. Upon notification from the Department, the licensee will comply and act immediately to terminate the employment of, remove from the facility or bar from entering the facility for any person it is deemed necessary while the Department considers granting or denying an exemption. Capacity and limitations as specified on the license are being maintained. Continue 809D

SUPERVISOR'S NAME: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Araceli GibsonTELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: EMPIRE HEAD START
FACILITY NUMBER: 503600291
VISIT DATE: 05/05/2022
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At least one person trained in CPR and Pediatric First Aid is present when children are at the facility or at offsite activities. The name of the child care center director or fully-qualified teacher designated to act in the director’s absence has been reported to the Department. Site supervisor will oversee that the facility continues to maintain signing children in/out of the facility by authorized representatives at the site. During today’s visit 5 children were signed in on for a future date and week (see 809D for further). All children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than 12 children in care when in person learning is conducted. LPA reviewed a sample of children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child and medical assessment. LPA reviewed a sample of staff files and observed files were complete with health screening, immunization records for influenza, pertussis and measles and current documentation of completed mandated reporter training. Menus are posted at least one week in advance where an authorized representative can view them.

Incidental Medical Services (IMS) are currently not being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.



LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D). Licensee was provided a copy of their appeal rights. This report shall be made available to the public. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Araceli GibsonTELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/05/2022 03:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710


FACILITY NAME: EMPIRE HEAD START
FACILITY NUMBER: 503600291

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101238(a)
Buildings and Grounds
(a) The child care center shall be clean, safe, sanitary and in good repair at all times to ensure the safety and well-being of children, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above while inspecting emergency exit leading toward the rear of the classroom LPA observed moderate amount of water, pooling and flooding, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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Site Supervisor agreed to have maintenance address the flooding. Site Supervisor will provide proof of repairs by plan of correction date 05/09/22.
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 children out of 15 children were signed in by authorized representatives on a future week and date, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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Site supervisor agrees to oversee and train staff on a way to maintain sign in sheets to reflect correct date signed by authorized representatives. Site Supervisor will provide an agenda of training signed by staff by Plan of correction date May 9, 2022.

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: Juvenal MoctezumaTELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Araceli GibsonTELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4