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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 540404986
Report Date: 01/29/2020
Date Signed: 01/30/2020 08:54:00 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:ST. PAUL'S SCHOOL PRE-SCHOOL ENRICHMENT PROGRAMFACILITY NUMBER:
540404986
ADMINISTRATOR:TIFFANY CONNORSFACILITY TYPE:
850
ADDRESS:6101 W. GOSHEN AVENUETELEPHONE:
(559) 739-1619
CITY:VISALIASTATE: CAZIP CODE:
93291
CAPACITY:50CENSUS: 45DATE:
01/29/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jennifer Peltzer - Director of Admissions TIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessika Thompson conducted an unannounced annual/random inspection. LPA met with Director of Admissions, Jennifer Peltzer. A tour of the facility, as shown on the facility sketch was performed. Snack is served daily; lunch is provided by parent’s and/or authorized representatives. There are no bodies of water. Firearms and ammunition are not on the premises. Furniture, equipment and materials are sufficient, age appropriate, in good repair and toxic free. Rooms and floors are safe and clean. The licensee is taking measures to keep the facility free of insects, rodents, etc. Conditions, limitations and capacity specified on license are in compliance. First Aid/CPR reviewed and in compliance. Teacher/child ratios are maintained, and adequate supervision is provided during visit. Menus are posted. A sample of children's and staff’s records reviewed. Children’s records include required information including; Name, address and telephone number of child’s authorized representative and relatives and/or others who can assume responsibility in the event authorized representative cannot be reached. Staff records contain required documentation of the educational background, training, and Child Abuse Mandated Reporter certification. Lead safety was discussed, and LPA provided Ms. Peltzer with a brochure. Licensee understands that lead safety information must also be provided to parents and/or authorized representatives of children in care. Provider Information Notices were discussed, and Ms. Peltzer is subscribed to receive updates via email effective today. Ms. Peltzer is aware that forms and updated information may be obtained on Community Care Licensing’s website, (www.ccld.ca.gov).

Incidental Medical Services (IMS) policy was discussed. Director Peltzer was advised that if/when any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department.

Per California Code of Regulations, Title 22, Division 12, the following deficiencies are found: (see LIC809-D)
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jessika ThompsonTELEPHONE: 559-341-4622
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2020
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: ST. PAUL'S SCHOOL PRE-SCHOOL ENRICHMENT PROGRAM
FACILITY NUMBER: 540404986
VISIT DATE: 01/29/2020
NARRATIVE
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In exit interview the licensee was advised of appeals rights and was provided with Appeals Rights. Licensee was also advised this report with Type A Deficiencies must be posted for 30 days where parents may easily view and filed in facility file for public review for 3 years.

Licensee is advised to make this licensing report accessible to the public and to provide copies of this licensing report and 809D with Type A citation to parents/legal guardians of children in care and to parents/legal guardians of children newly enrolled at the facility during the next 12 months.

Licensee is to keep verification of receipt (LIC9224) in each child's file at the facility.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS
SUPERVISOR'S NAME: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jessika ThompsonTELEPHONE: 559-341-4622
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2020
LIC809 (FAS) - (06/04)
Page: 2 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: ST. PAUL'S SCHOOL PRE-SCHOOL ENRICHMENT PROGRAM
FACILITY NUMBER: 540404986
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2020
Section Cited

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department.
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This requirement was not met as evidenced by LPA's observations & information obtained by LPA during records review. Today, LPA witnessed Staff #1, Staff #2, and Staff #3 caring for children within the Child Care Center(CCC). During records review, LPA confirmed that Staff #1, Staff #2, and Staff #3 are not fingerprint cleared through the Department, and associated to this CCC as required. This poses an immediate health, safety, or personal rights risk to children in care. A civil penalty of $1200.00 was assessed.
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Ms. Peltzer was advised that until criminal background clearance is obtained, the aforementioned staff members are not permitted to provide child care services at the CCC.

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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: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jessika ThompsonTELEPHONE: 559-341-4622
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2020
LIC809 (FAS) - (06/04)
Page: 3 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: ST. PAUL'S SCHOOL PRE-SCHOOL ENRICHMENT PROGRAM
FACILITY NUMBER: 540404986
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/29/2020
Section Cited

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Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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This requirement was not met, as evidenced by records review conducted by LPA. Today, during records review, the licensee was unable to provide proof of influenza, pertussis, and measles immunization for Staff #4 & Staff #5. This poses a potential Health and Safety risk to children in care.

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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: Diana deLeonTELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jessika ThompsonTELEPHONE: 559-341-4622
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4