503810076-8-9-2019-04-CC-CBRN-BEVP86-20190809110501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 503810076
Report Date: 08/09/2019
Date Signed: 08/09/2019 11:05:10 AM

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:	HAZEL'S CHRISTIAN PRESCHOOL & CHILD CARE CENTER		FACILITY NUMBER:	503810076
ADMINISTRATOR:	DOMSON, ODOOM/HAZEL		FACILITY TYPE:	830
ADDRESS:	920 ILA WAY		TELEPHONE:	(209) 735-9359
CITY:	MODESTO	STATE: CA	ZIP CODE:	95354
CAPACITY:	20	CENSUS: 0	DATE:	08/09/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	07:30 AM
MET WITH:	Hazel Domson		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A prelicensing inspection visit was conducted on this date by Licensing Program Analyst (LPA) Cynthia Brannon, who met with Licensee/Director, Hazel Domson. This program will operate year round, daily from 6:00 AM to 7:00 PM from Monday thru Friday. Morning and afternoon snacks provided and prepared at facility. Parents are responsible for providing formula, diapers and meals. There is a sink with hot water inside kitchen. Ill children and staff will utilize the bathroom located in the office. Ill children will be isolated in the office. Room measurements taken and reviewed with Hazel Domson. The infant square footage is 308 which will accommodate 8 infants. Crib area available and can accommodate 8 cribs. Refrigerator available for infant formula, bottles, infant food. There is a changing table with cushioning and 3" sides within arm’s length from sink. This sink is not to be used for food preparation. There is a toilet, and three potty training chairs. Adequate storage space available for children's belongings. Outdoor storage is available for toys and equipment. Toys and equipment are age appropriate. CONTINUED ON FOLLOWING PAGE

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Cynthia Brannon	TELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: HAZEL'S CHRISTIAN PRESCHOOL & CHILD CARE CENTER	FACILITY NUMBER: 503810076
	VISIT DATE: 08/09/2019

NARRATIVE

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Outdoor measurements taken on this date total 1148 square feet which will accommodate the capacity of eight. Adequate shade is available in the outdoor activity area. Licensee is utilizing a mature tree and two pop-up tents that are anchored to the ground.
Licensee is utilizing pitcher of water with a disposable cup dispenser and cups for indoor and outdoor drinking water.. There is/in not a drinking water fountain, Igloo will be utilized for indoor/outdoor drinking water.
The fire clearance has been received and approved.
This facility provides Incidental Medical Services – IMS. 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: http://www.ada.gov/childqanda.htm

CONTINUED ON FOLLOWING PAGE

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Cynthia Brannon	TELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: HAZEL'S CHRISTIAN PRESCHOOL & CHILD CARE CENTER	FACILITY NUMBER: 503810076
	VISIT DATE: 08/09/2019

NARRATIVE

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Pending a final file review and completion of above items, a recommendation will be made to license the above facility for a capacity of 8 infants and up to 8 crib babies.

The following documents should be posted at the facility:
* PUB 269- Child passenger restraint systems poster 101225(f) Transportation
* Pub 393- Notification of Parents Rights 101218.1(c) Admission Procedures
* License 101160(a) License
* Menus 101227(a)(6) Food Services
* LIC 613A- Personal Rights form 101223(b)(2) Personal Rights
* LIC 610- Disaster Plan 101174(a)
* LIC 9148- Earthquake Preparedness Checklist 101174(b)

To order forms, etc. visit our website at www.ccld.ca.gov.

SUPERVISOR'S NAME: Michael Duarte	TELEPHONE: (559) 650-7874
LICENSING EVALUATOR NAME: Cynthia Brannon	TELEPHONE: (559) 341-5155
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019

LIC809 (FAS) - (06/04)

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