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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 550318064
Report Date: 02/04/2020
Date Signed: 02/04/2020 01:32:20 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:BELLEVIEW SCHOOLFACILITY NUMBER:
550318064
ADMINISTRATOR:WILEY, NORMANFACILITY TYPE:
850
ADDRESS:22736 KEWIN MILL RDTELEPHONE:
(209) 586-5510
CITY:SONORASTATE: CAZIP CODE:
95370
CAPACITY:24CENSUS: 5DATE:
02/04/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kim AngelTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Justin Denton met with Director Kim Angel for the purpose of an annual random inspection. LPA toured the program site including all activity and classroom spaces, restrooms, and outdoor play areas. LPA observed appropriate ratios, care and supervision, and capacity during the visit.

Medications and hazardous items were stored inaccessibly to children. Furniture, equipment, and play materials were in good condition. Playground equipment was free of loose and sharp parts. The areas under and around playground climbing equipment were cushioned with materials to absorb falls. Toileting facilities were in operating, safe, and sanitary condition. Uncontaminated drinking water was readily available to children both indoors and outdoors. Breakfast menu was posted in a visible area. Breakfast is provided to children in the elementary school cafeteria. LPA observed Sign In/Out Sheet with signatures, times, and dates.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. LPA observed expired medical device for one child. 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
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2020
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: BELLEVIEW SCHOOL
FACILITY NUMBER: 550318064
VISIT DATE: 02/04/2020
NARRATIVE
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Children’s records were reviewed and were separate files, and included contact information of responsible parties. At least one person present today had current Pediatric CPR and First Aid certification (expires 02/2020). LPA discussed the Departmental inspection authority, and also informed the Licensee that any changes regarding the Center Director or their Designee must be reported to Department within 10 working days.

An Exit Interview was conducted. A Notice of Site Visit was provided. Licensee was encouraged to the visit the Departmental website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, provider information notices, regulations and legislation pertaining child care centers.

Title 22 Deficiencies has been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: BELLEVIEW SCHOOL
FACILITY NUMBER: 550318064
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2020
Section Cited

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Health-Related Services: Prescription medications shall be administered in accordance with the label directions as prescribed by the child's physician. This requirement was not met as evidenced by:

LPA observed a medical device (epi-pen) that expired in 08/2019. This is an immediate
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risk to the health and safety of 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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2020
LIC809 (FAS) - (06/04)
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