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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573615400
Report Date: 09/29/2023
Date Signed: 09/29/2023 10:22:49 AM


Document Has Been Signed on 09/29/2023 10:22 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:YCOE ALYCE NORMAN HSFACILITY NUMBER:
573615400
ADMINISTRATOR:JACQUELINE TAMFACILITY TYPE:
850
ADDRESS:1200 ANNA STREETTELEPHONE:
(916) 375-7650
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95605
CAPACITY:144CENSUS: 102DATE:
09/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Site Coordinator, Jackie TamTIME COMPLETED:
10:45 AM
NARRATIVE
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On September 29, 2023, Licensing Program Analyst (LPA) Lauren Scott met with Site Coordinator, Jackie Tam for the purpose of an unannounced Case Management inspection. LPA observed 102 children supervised by 27 staff.

On September 26, 2022, facility contacted CCLD regarding an Unusual Incident Report (UIR) that stated that 13 children in Preschool Room 1 were taken to the bathroom by 2 staff. When the 2 staff returned, they counted 12 children and realized one was missing. One staff returned to the restroom and found one child still inside the restroom. LPA conducted interviews with staff and learned the child was left in the bathroom for approximately 3 minutes.

Based on the interviews and information obtained, one Title 22 Deficiency has been issued on the attached LIC 809-D. The facility was informed that this report dated 9/29/2023 documents one Type A citation which shall be posted for 30 consecutive days. The facility shall also provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. Because the citation involved an absence of supervision, an immediate civil penalty of $500 has been issued. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Facility has been provided with appeal rights.

Exit interview conducted and report was reviewed with Site Coordinator, Jackie Tam. A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Lauren ScottTELEPHONE: (916) 926-9488
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
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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Document Has Been Signed on 09/29/2023 10:22 AM - 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: YCOE ALYCE NORMAN HS
FACILITY NUMBER: 573615400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2023
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision... (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:
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Facility stated they are enforcing walking loops for children to hold to stay together as well as verbally stating number of children they have before leaving a room. Facility will also begin taking smaller groups to the bathroom. These changes are already in place.
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Based on interviews, the facility did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons 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: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: Lauren ScottTELEPHONE: (916) 926-9488
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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