525402367-6-6-2023-13-CC-PDGA-CSJUMR-20230606154245

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 525402367
Report Date: 06/06/2023
Date Signed: 06/06/2023 03:43:21 PM

Document Has Been Signed on 06/06/2023 03:43 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
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME:	EVERGREEN STATE PRESCHOOL		FACILITY NUMBER:	525402367
ADMINISTRATOR:	RULON, CRYSTAL		FACILITY TYPE:	850
ADDRESS:	19415 HOOKER CREEK ROAD		TELEPHONE:	(530) 347-3411
CITY:	COTTONWOOD	STATE: CA	ZIP CODE:	96022
CAPACITY:	48	CENSUS: 29	DATE:	06/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Crystal Rulon		TIME COMPLETED:	03:00 PM

NARRATIVE

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On 6/6/23 at 12:30 PM, an annual inspection was made to the facility by Licensing Program Analysts (LPA), Pearl DiGenova and Sydney Sims. The LPA met with director Crystal Rulon. This program is operated by Evergreen Union School District The facility operates 8 AM to 3 PM, Monday–Friday. The facility was toured at 2:00 PM inside and outside and the floor and yard plan submitted by the licensee were verified. Facility operates in rooms 29 and 31.
3 teachers and 2 aides were supervising 29 children, and operating within the licensed capacity and ratio requirements. There are no pools or bodies of water on the premises.

5 children's records were reviewed at 12:48 PM. 5 staff records were reviewed at 1:00PM.

Director Crystal Rulon 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Pearl DiGenova	TELEPHONE: 530-895-5821
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: EVERGREEN STATE PRESCHOOL	FACILITY NUMBER: 525402367
	VISIT DATE: 06/06/2023

NARRATIVE

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The following deficiencies were cited (see LIC 809D):

Lead testing of the drinking faucets was not completed during the required time frame.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the director Crystal Rulon.

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.

SUPERVISOR'S NAME: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Pearl DiGenova	TELEPHONE: 530-895-5821
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/06/2023 03:43 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
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: EVERGREEN STATE PRESCHOOL	FACILITY NUMBER: 525402367
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.16(a)(1)

Lead Testing

(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as lead testing wasn't completed until 4/12/32 which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2023
	Plan of Correction
1 2 3 4	Lead testing results were recieved 6/6/23.

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: Megan Aviles	TELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Pearl DiGenova	TELEPHONE: 530-895-5821
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC809 (FAS) - (06/04)

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