540406725-3-29-2022-04-CC-NHER-CCYSUQ-20220329141130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 540406725
Report Date: 03/29/2022
Date Signed: 03/29/2022 02:11:56 PM

Document Has Been Signed on 03/29/2022 02:11 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	PALO VERDE PRESCHOOL		FACILITY NUMBER:	540406725
ADMINISTRATOR:	ANDERSON, PHIL		FACILITY TYPE:	850
ADDRESS:	9637 AVENUE 196		TELEPHONE:	(559) 688-0648
CITY:	TULARE	STATE: CA	ZIP CODE:	93274
CAPACITY:	24	CENSUS: 24	DATE:	03/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Laura DeRosa		TIME COMPLETED:	02:30 PM

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	On 03/29/2022 Licensing Program Analyst (LPA) Nancy Her, conducted an unannounced Annual Required Inspection for the preschool license. LPA met with Lead Teacher Laura DeRosa and toured the facility indoors and outdoors. This facility has one session from 8:30 AM to 2:20 PM and operates on the traditional school year. 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 are made inaccessible. All poisons are kept in a locked storage area. 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. All toilets and handwashing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. All kitchen, food preparation and storage areas are clean, free of litter/rubbish and free of rodents/vermin. All food is protected against contamination and any contaminated food is discarded immediately. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors. Areas around high climbing equipment, swings and slides have cushioning material to absorb falls. The facility is free of flies, insects and rodents. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. 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 offsite activities. The name of the child care center director or fully-qualified teacher(s) designated to act in the director’s absence has been reported to the Department. The person who signs the child in/out of the facility shall use their full legal signature and record the time of day. All children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than 12 children in care. Continued on 809-C

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Nancy Her	TELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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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Document Has Been Signed on 03/29/2022 02:11 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: PALO VERDE PRESCHOOL	FACILITY NUMBER: 540406725
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) 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. 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. Staff members did not have immunization records verifying that staff has been immunized against influenza, pertussis, and measles, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	Licensee will have staff members obtain immunization against influenza, pertussis, and measles, and submit verification to Fresno Community Care Licensing by 04/29/2022.

Type B

Section Cited

CCR

101216(g)(2)

Personnel Requirements

(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following: 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. Staff members do not have a health-screening report which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2022
	Plan of Correction
1 2 3 4	Licensee will have staff members obtaina health-screening report and submit verification to Fresno Community Care Licensing by 04/29/2022.

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: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Nancy Her	TELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/29/2022 02:11 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: PALO VERDE PRESCHOOL	FACILITY NUMBER: 540406725
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216(l)(1)(B)

Personnel Requirements

(B) A copy of the signed LIC 9052 (11/94) shall be kept in the employee's personnel record. 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. Staff members did not have a signed LIC 9052 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2022
	Plan of Correction
1 2 3 4	Licensee will have staff members sign LIC 9052 and submit a copy to Fresno Community Care Licensing by 04/08/2022.

Type B

Section Cited

CCR

101217(a)(13)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) A signed statement regarding their criminal record history as required by Section 101170(d). 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. Staff members did not have a signed statement regarding their criminal record history as required by Section 101170(d). which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2022
	Plan of Correction
1 2 3 4	Licensee will have staff members sign a statement regarding their criminal record history and submit a copy to Fresno Community Care Licensing by 04/08/2022.

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: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Nancy Her	TELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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: PALO VERDE PRESCHOOL	FACILITY NUMBER: 540406725
	VISIT DATE: 03/29/2022

NARRATIVE

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LPA reviewed a sample of children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child and medical assessment. LPA reviewed a sample of staff files and observed files were incomplete with health screening, immunization records for influenza, pertussis and measles and current documentation of completed mandated reporter training. Menus are posted at least one week in advance where an authorized representative can view them.

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

LPA and Licensee 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 deficiencies are being cited: (see next page, 809 D)

Exit interview conducted and report was reviewed with the facility representative Laura DeRosa.
A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Nancy Her	TELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/29/2022 02:11 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: PALO VERDE PRESCHOOL	FACILITY NUMBER: 540406725
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101221(b)(8)(C)

(C) A signed consent form for emergency medical treatment unless the child's authorized representative has signed the statement specified in Section 101220(f). 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. All children's files were missing a signed consent form for emergency medical treatment which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2022
	Plan of Correction
1 2 3 4	Licensee will have parents/authorized representatives sign a signed consent form for emergency medical treatment for their child and submit 10 children's copies to Fresno Community Care Licensing by 04/08/2022.

Type B

Section Cited

CCR

101229.1(b)

(b) The person who brings the child to, and removes the child from, the center shall sign the child in/out. 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. Staff member is signing children in due to parents not dropping children off at preschool entrance which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2022
	Plan of Correction
1 2 3 4	Licensee will have parents/authorized representatives sign children in/out and submit one week of sign in/out sheet to Fresno Community Care Licensing by 04/08/2022.

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: Duane Matsubara	TELEPHONE: (559)650-7855
LICENSING EVALUATOR NAME: Nancy Her	TELEPHONE: (559) 341-5422
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

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