240407459-1-26-2022-04-CC-JPAO-CB2RXK-20220126122454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 240407459
Report Date: 01/26/2022
Date Signed: 01/26/2022 12:25:07 PM

Document Has Been Signed on 01/26/2022 12:25 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	ADA GIVENS PRESCHOOL		FACILITY NUMBER:	240407459
ADMINISTRATOR:	MEJIA, MARIA		FACILITY TYPE:	850
ADDRESS:	2900 GREEN STREET		TELEPHONE:	(209) 385-6378
CITY:	MERCED	STATE: CA	ZIP CODE:	95340
CAPACITY: 22	TOTAL ENROLLED CHILDREN: 22	CENSUS: 13	DATE:	01/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Lynnette Gomez - Program Support Teacher		TIME COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/26/22 Licensing Program Analyst (LPA) Joseph Pacheco, conducted an unannounced Annual Required Inspection for the preschool license. LPA met with Program Support Teacher (PST), Lynnette Gomez and toured the facility indoors and outdoors. This facility operates an AM and PM session Monday through Friday on a traditional school year schedule. AM session is 8:00 – 11:00, PM session is 11:50 – 2:50. PST verified facility phone number is (209) 385-6378. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible. No poisons were observed during the inspection. Furniture and equipment are in good condition, free of sharp, loose or pointed parts. Playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All toilets and handwashing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. Food is prepared at the Ada Givens Elementary School cafeteria and delivered daily. All food is protected against contamination and any contaminated food is discarded immediately. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors. Areas around high climbing equipment, swings and slides have cushioning material to absorb falls. The facility is free of flies, insects and rodents. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. Staff are fingerprint cleared as a condition of employment through Merced City School District. Capacity and limitations as specified on the license are being maintained. LPA did not observe a current CPR card in staff files during today's inspection. The name of the child care center (CCC) director or fully-qualified teacher(s) designated to act in the director’s absence has been reported to the Department. The person who signs the child in/out of the facility shall use their full legal signature and record the time of day. All children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than 12 children in care. CONTINUED ON 809-C

SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

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 01/26/2022 12:25 PM - It Cannot Be Edited

Created By: Joseph Pacheco On 01/26/2022 at 11:40 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: ADA GIVENS PRESCHOOL	FACILITY NUMBER: 240407459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation of staff files. LPA observed that two staff did not have documentation of measles and pertussis as required by regulations. This poses a potential health, safety or personal rights risk to children in care.
	POC Due Date: 02/09/2022
	Plan of Correction
1 2 3 4	Facility representative stated she will provide documentation of required immunizations to Community Care Licensing by 2/9/22.

Type B

Section Cited

CCR

101216(f)

Personnel Requirements

(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation of staff files. LPA observed that none of the staff present during today's inspection had documentation of a current CPR card. One staff member was a substitute. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/09/2022
	Plan of Correction
1 2 3 4	Facility representative stated she will write a plan to ensure compliance with this regulation going forward and provide the plan to Community Care Licensing by 2/9/22.

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:

Diana deLeon

LICENSING EVALUATOR NAME:

Joseph Pacheco

LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: ADA GIVENS PRESCHOOL	FACILITY NUMBER: 240407459
	VISIT DATE: 01/26/2022

NARRATIVE

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LPA reviewed a sample of children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child. LPA did not observe a written medical assessment in two children’s files.
LPA reviewed a sample of staff files and observed files were complete with health screening. Two staff files were missing immunization records for measles and pertussis and current documentation of completed mandated reporter training. Menus are posted at least one week in advance where an authorized representative can view them.

Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

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/process.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiencies are being cited: (see next page, 809 D). Licensee was provided a copy of their appeal rights.

Exit interview conducted and report was reviewed with the Program Support Teacher, Lynnette Gomez.

This report shall be made available to the public upon request. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2022

LIC809 (FAS) - (06/04)

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