503808081-7-7-2022-04-CC-JYAZ-CG4VH3-20220707162627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 503808081
Report Date: 07/07/2022
Date Signed: 07/07/2022 04:27:05 PM

Document Has Been Signed on 07/07/2022 04:27 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	GRACE LUTHERAN SCHOOL - EXTENDED SCHOOL CARE		FACILITY NUMBER:	503808081
ADMINISTRATOR:	VIGARS, JEFF		FACILITY TYPE:	840
ADDRESS:	617 W. ORANGEBURG AVENUE		TELEPHONE:	(209) 529-1800
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	50	CENSUS: 18	DATE:	07/07/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Jennifer Spiker		TIME COMPLETED:	04:45 PM

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On 07/07/2022, Licensing Program Analyst (LPA) Jeovanna Yanez conducted an unannounced Annual Required Inspection for the school age license. LPA met with Director, Jennifer Spiker and toured the facility indoors and outdoors. The facility is housed on the Grace Lutheran Church premises, and Rooms 7, 9, the gymnasium and library were inspected as they are still used for care. Days and hours of operation are Monday to Friday, 7:00 AM – 6:00 PM for the 8 to 9 weeks during the summer.

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 were 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, free of sharp, loose, or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All toilets and hand washing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. The facility provides prepackaged snacks during the day, and children can bring lunch from home. All kitchen, food preparation and storage areas are clean, free of litter/rubbish and free of rodents/vermin. All foods/beverages capable of rapid spoiling are stored in covered containers at 45F or less. Solid waste storage containers have tight-fitting covers and are in good repair. Menus are posted at least one week in advance where an authorized representative can view them. Drinking water is available both indoors and outdoors. Areas around high climbing equipment and slides have cushioning material to absorb falls. All materials and surfaces accessible to children are toxic free. The facility is free of flies, insects and rodents. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. A review of the facility records show that this facility has not conducted a fire drill within the last six months. Capacity and limitations as specified on the license are being maintained. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility or at off site activities. All children are under supervision, including visual supervision, of a teacher at all times. (Continued on 809-c)

SUPERVISOR'S NAME: Juvenal Moctezuma	TELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Jeovanna Yanez	TELEPHONE: (559) 341-5629
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GRACE LUTHERAN SCHOOL - EXTENDED SCHOOL CARE	FACILITY NUMBER: 503808081
	VISIT DATE: 07/07/2022

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Facility maintains a ratio of one teacher supervising no more than 12 children in care. LPA reviewed a sample of children’s files and observed files were complete with contact information for authorized representative/relatives/others who can assume responsibility for the child. LPA reviewed a sample of staff files and observed files were complete with documentation of meeting qualification requirements, and current documentation of completed mandated reporter training. Facility representative was reminded that all adults 18 and over, 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.

This facility provides Incidental Medical Services – IMS. Currently, there are no children enrolled who need medication administer, nor did the facility have any medications. 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: http://www.ada.gov/childqanda.htm

LPA and Director 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D). Licensee was provided a copy of their appeal rights.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with facility representative, Jennifer Spiker. This report shall be made available to the public upon request.

SUPERVISOR'S NAME: Juvenal Moctezuma	TELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Jeovanna Yanez	TELEPHONE: (559) 341-5629
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/07/2022 04:27 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
FRESNO-CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: GRACE LUTHERAN SCHOOL - EXTENDED SCHOOL CARE	FACILITY NUMBER: 503808081
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101174(d)

Disaster and Mass Casualty Plan

(d) Disaster drills shall be conducted at least every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that a fire drill has not been conducted for the school age license, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/21/2022
	Plan of Correction
1 2 3 4	Director stated she will complete a fire drill and submit proof of completion by sending a copy of a fire drill log to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moctezuma	TELEPHONE: (559) 650-7869
LICENSING EVALUATOR NAME: Jeovanna Yanez	TELEPHONE: (559) 341-5629
LICENSING EVALUATOR SIGNATURE:	DATE: 07/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022

LIC809 (FAS) - (06/04)

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