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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570311280
Report Date: 03/05/2020
Date Signed: 03/05/2020 11:29:11 AM

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:MERRYHILL SCHOOL-LA VIDAFACILITY NUMBER:
570311280
ADMINISTRATOR:MCSPADDEN, JILLFACILITY TYPE:
850
ADDRESS:222 LA VIDA WAYTELEPHONE:
(530) 753-9210
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:88CENSUS: 64DATE:
03/05/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mieko Rogers and Morgan CallawayTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Chayntel Hunter and Amy Silva met with Assistant Principal, Mieko Rogers and Office Administrator, Morgan Callaway to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 02/17/20. During today's visit the facility was toured. Present were 64 preschoolers with 9 staff.

LPAs interviewed the Assistant Principal and and collected statements from teachers who were present during the incident. LPAs reviewed and discussed this report with the Assistant Principal.

The facility reported the UIR to Community Care Licensing within 24hrs. A written UIR was submitted within 7 days, describing the specifics of the incident.

The following Title 22 Deficiency is being cited on the subsequent 809-D page. Upon receipt of Type A citations, licensee shall post and provide copies of the LIC 809-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 809-D in each child's file. Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.
SUPERVISOR'S NAME: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: MERRYHILL SCHOOL-LA VIDA
FACILITY NUMBER: 570311280
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2020
Section Cited

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Responsibility for Providing Care and Supervision 101229 (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time… This requirement was not met as evidenced by:

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Based on interviews, it was revealed that C1 was left outside on 02/07/2020 during the classroom's walk.
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Facility also purchased walkie talkies for staff.

LPAs will clear deficiency during today's inspection.

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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: Sharon OgbodoTELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2020
LIC809 (FAS) - (06/04)
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