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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243808218
Report Date: 08/27/2021
Date Signed: 08/27/2021 01:24:29 PM

Document Has Been Signed on 08/27/2021 01:24 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:PETERSON PRESCHOOLFACILITY NUMBER:
243808218
ADMINISTRATOR:WILLIAMS, KARIEFACILITY TYPE:
850
ADDRESS:848 E DONNA DRTELEPHONE:
(209) 385-6700
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY: 24TOTAL ENROLLED CHILDREN: 0CENSUS: 14DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Karie Williams - Site SupervisorTIME COMPLETED:
01:30 PM
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On 8/27/21 Licensing Program Analyst (LPA) Joseph Pacheco, conducted an unannounced Annual Required Inspection for the preschool license. LPA met with Site Supervisor, Karie Williams, and toured the facility indoors and outdoors. This facility operates an AM and PM session. AM hours are 8:20 – 11:20, PM Hours are 12:10 – 3:10.
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. LPA observed weeds on the surface of the outdoor activity space. Areas around high climbing equipment, swings and slides have cushioning material to absorb falls. 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 Peterson 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. 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. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility or at offsite activities. The name of the child care center 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. 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 and medical assessment.
CONTINUED ON 809-C
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: PETERSON PRESCHOOL
FACILITY NUMBER: 243808218
VISIT DATE: 08/27/2021
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LPA reviewed a sample of staff files and observed files were complete with health screening, immunization records for influenza, pertussis and measles 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 currently being provided. Facility has an IMS plan on file. 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.

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

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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Document Has Been Signed on 08/27/2021 01:24 PM - It Cannot Be Edited


Created By: Joseph Pacheco On 08/27/2021 at 01:00 PM
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: PETERSON PRESCHOOL
FACILITY NUMBER: 243808218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/10/2021
Section Cited
CCR
101238.2(d)(2)

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Outdoor Activity Space. (d) The surface of the outdoor activity space shall be maintained: (2) Free of hazards. This requirement was not met as evidenced by LPA observation of weeds in the outdoor play area. This is a potential risk to the health, safety or personal rights of children in care.
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Site Supervisor stated she will report the weed hazards to the elementary school maintenance staff and have the weeds removed. Site Supervisor to submit proof of removal to Community Care Licensing by 9/10/21.

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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:Diana deLeon
LICENSING EVALUATOR NAME:Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2021


LIC809 (FAS) - (06/04)
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