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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570312613
Report Date: 09/05/2019
Date Signed: 09/05/2019 12:52:54 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:PIONEER SCHOOL AGE CHILD DEVELOPMENT CENTERFACILITY NUMBER:
570312613
ADMINISTRATOR:RFACILITY TYPE:
840
ADDRESS:5131 HAMEL STREETTELEPHONE:
(530) 758-0611
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY:64CENSUS: 11DATE:
09/05/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Breezie Norris, Site Supervisor TIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Charlotte Baney and Chayntel Hunter met with Site Supervisor, Breezie Norris to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 8/30/19. During today's visit the facility was toured. Present were 11 school age children in care and 3 staff.

LPAs interviewed the Site Supervisor and teachers who were present during the incident. LPAs reviewed and discussed this report with the Site Supervisor.

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: 09/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019
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: PIONEER SCHOOL AGE CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 570312613
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2019
Section Cited

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CCR 101229(a)(1) No child(ren) shall be left without the supervision of a teacher at any time. Supervision shall include visual observation. This requirement was not met as evidenced by: LPAs learned on 8/30/19 from the Site Supervisor that a child was left in the center during the transition to the elementary
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school. The child had went to the bathroom, after the inside count was taken prior to exiting the building, and was brought to the Site Supervisor, who was at the elementary school classrooms, by an unknown parent. This is an immediate health and safety risk to children.
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transitions are suitable. The Site Supervisor will send a copy of the minutes and attendance list to LPA Hunter.

chayntel.hunter@dss.ca.gov

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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: 09/05/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2019
LIC809 (FAS) - (06/04)
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