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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 550320020
Report Date: 06/12/2023
Date Signed: 06/12/2023 11:09:40 AM


Document Has Been Signed on 06/12/2023 11:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:AMADOR-TUOLUMNE COMMUNITY ACTION AGENCY HEAD STARTFACILITY NUMBER:
550320020
ADMINISTRATOR:JESSICA HOLDENFACILITY TYPE:
850
ADDRESS:18234 FOURTH AVENUETELEPHONE:
(209) 984-1617
CITY:JAMESTOWNSTATE: CAZIP CODE:
95327
CAPACITY:20CENSUS: 0DATE:
06/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:lead center teacher, Ashley JohnsonTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Lauren Scott met with lead center teacher, Ashley Johnson for the purpose of an unannounced annual inspection. Facility days and hours of operation are Monday-Friday from 8:30 AM to 2:30 PM. Facility closes June-August every year.

LPA toured the facility inside and out. LPA observed that hazardous items (disinfectants, cleaning solutions etc.) were inaccessible to children in care. LPA reviewed sign in and outs book, staffing ratios, first aid supplies, furniture, equipment, fire drills and drinking water. LPA observed all required forms to be posted. LPA observed functioning carbon monoxide and smoke alarms. There are adequate toys and equipment available for children. Outdoor play area was toured, the play structure appeared to be in good repair, and there is sufficient cushioning (wood chips) under the play structure. Facility provides breakfast, lunch and snack to children in care. All food is prepared on site. Kitchen was toured at the time of inspection.

All staff present during today's inspection have a fingerprint clearance. Licensee 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.

LPA reviewed children’s and staff files. LPA observed health screening reports with TB test and required MMR and TDAP vaccines. At least one staff member present today has current Pediatric CPR and First Aid. LPA observed AB1207 Mandated Reporter training certificates for all staff. The site supervisor was reminded to renew the course every 2 years through www.mandatedreporterca.com website. Report continues on 809-C

SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Lauren ScottTELEPHONE: (916) 926-9488
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023
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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: AMADOR-TUOLUMNE COMMUNITY ACTION AGENCY HEAD START
FACILITY NUMBER: 550320020
VISIT DATE: 06/12/2023
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This provider is not currently providing Incidental Medical Services (IMS) services to children in care. IMS policy was discussed at the time of inspection. 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

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/inspection-process.

Exit interview conducted and report was reviewed with the lead center teacher, Ashley Johnson. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during the inspection.
SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Lauren ScottTELEPHONE: (916) 926-9488
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
LIC809 (FAS) - (06/04)
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