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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 033605372
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:59:30 PM

Document Has Been Signed on 05/04/2023 01:59 PM - 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:PLYMOUTH STATE PRESCHOOLFACILITY NUMBER:
033605372
ADMINISTRATOR:HOLLINGSWORTH, TAMARANFACILITY TYPE:
850
ADDRESS:18601 SHERWOOD STREETTELEPHONE:
(209) 283-0844
CITY:PLYMOUTHSTATE: CAZIP CODE:
95669
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: DATE:
05/04/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrative Assistant: Anrea RotarTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Mariya Melnichuk met with Administrative Assistant, Andrea Rotar on 5/04/2023 at the district office at: 217 Rex Avenue Jackson CA 95642 for the purpose of an unannounced plan of correction inspection to clear a Type B deficiency, which was issued on 4/05/23 for missing files of staff.

All individuals subject to criminal background review have obtained a criminal record clearance. Facility representative was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home. 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.



During today's inspection LPA observed completed files for all staff working at Plymouth State Preschool.

Deficiency cited on 4/05/2023 is cleared effective today. Proof of correction letter was provided .LPA also provided a copy of correction letter and Notice of Site Visit posting via email to Director Michelle Pechette.

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.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Mariya Melnichuk
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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