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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 525402367
Report Date: 12/04/2019
Date Signed: 12/04/2019 01:49:22 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:EVERGREEN STATE PRESCHOOLFACILITY NUMBER:
525402367
ADMINISTRATOR:NUZUM, BRITTNEYFACILITY TYPE:
850
ADDRESS:19415 HOOKER CREEK ROADTELEPHONE:
(530) 347-3411
CITY:COTTONWOODSTATE: CAZIP CODE:
96022
CAPACITY:48CENSUS: 41DATE:
12/04/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Karen Provence TIME COMPLETED:
12:25 PM
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An inspection was made to the facility by Licensing Program Analyst, Wisehart The facility file was reviewed prior to this visit. This is a Title 5 preschool operated by Evergreen School District in rooms 29 and 31 of Evergreen Elementary School. All staff are employed by the school district.

Operating hours are 8am-12pm and 12pom-4pm in room 29 and 8am-12pm, 12:30-3:30 in room 31, Mon-Fri. The facility was toured inside and outside and the floor and yard plan were verified. The items which could pose a danger to children (detergents, cleaning compounds and medications) were inaccessible to children. Poisons are locked in the school maintenance department. The facility was free of flies, insects and rodents. The toys, floors, desks and other equipment and surfaces appeared clean, toxic free, safe and in good condition. There is uncontaminated drinking water available to children both indoors (sink area) and outdoors (playground) via water foundations. The children's bathrooms appeared in safe and sanitary condition. A current menu was posted on parent boards near entrance. Food prep by the elementary school cafeteria. The playground was free of hazards. Fire Drills were conducted on 11/1/19 and 11/19/19. The playground equipment and surface areas appeared in safe condition. There is wood chip cushioning underneath climbing structures and/or play equipment sufficient to absorb falls. There were no bodies of water observed. The director stated no weapons are stored on site and none were observed. During today's inspection, Title 5 staffing ratios were being met and children were being properly supervised. The facility was operating within the licensed capacity. At least one staff member present possessed current CPR and First Aid certifications (expires 8/5/21).
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Carrie WisehartTELEPHONE: (530) 895-5824
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: EVERGREEN STATE PRESCHOOL
FACILITY NUMBER: 525402367
VISIT DATE: 12/04/2019
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Twenty Children’s records were reviewed at 11:12 am and contained identification forms with authorized representative information. Four staff records were reviewed at 11:45 pm and contained mandated reporter training. This facility is providing Incidental Medical Services – IMS. Incidental Medical Services (IMS) policy was discussed. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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 director. 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.

There were no Title 22 deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Carrie WisehartTELEPHONE: (530) 895-5824
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2