313624423-7-31-2025-03-CC-LHAM-DK4NAQ-20250731101756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313624423
Report Date: 07/31/2025
Date Signed: 07/31/2025 10:18:02 AM

Document Has Been Signed on 07/31/2025 10:18 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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	CREEKSIDE OAKS ELEMENTARY PRESCHOOL		FACILITY NUMBER:	313624423
ADMINISTRATOR/ DIRECTOR:	AIMEE BOUCHER		FACILITY TYPE:	850
ADDRESS:	2030 1ST ST		TELEPHONE:	(530) 745-1380
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY: 24	TOTAL ENROLLED CHILDREN: 24	CENSUS:	DATE:	07/31/2025
TYPE OF VISIT:	Case Management - Licensee Initiated	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Daniel Mendoza		TIME VISIT/ INSPECTION COMPLETED:	10:25 AM

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 Thursday, July 31,2025, Licensing Program Analysts (LPA) Lea Habtom and Amanda Sutter met with the Program Manager, Daniel Mendoza, to conduct a case management visit for a room change. The facility is located on the campus of Creekside Oaks Elementary School. LPAs toured the facility, no children were in care. Facility requests the room change from K1 to Room 9 on the Creekside Oaks Elementary school campus. The capacity will remain the same as the previous room K1 of 24 children. LPA has received the required fire clearance for the capacity of 24 children for Room 9 from Lincoln Fire Department on July 1, 2025. INDOOR ACTIVITY SPACE: The classroom is equipped with child size furnishings and a sufficient number of cubbies and hooks for storing children's personal belongings. The facility plans to move more items as needed from storage. The facility operates two half day program and no naps will be offered. The half day programs hours are as follows Monday- Friday 8:00 am- 11:00 am and 12:00 pm- 3:00 pm. There is a refrigerator, a microwave, and a sink in the classroom; snacks will be stored in the locked cabinet and the refrigerator. LPAs observed the first aid kit. LPA observed functional water fountains in the classroom and outdoor play area. The facility plans to test the room for lead. There is a functional carbon monoxide detector. The classroom was measured. The classroom contains a total of 881.4057 square feet, which will accommodate the applicants' request for 24 preschool children. The program will be utilizing the bathroom on the school campus. A waiver was requested for the shared use of the bathroom space and one will be granted. There are a total of 6 toilets, 6 sinks and 2 urinals between the boys and girls bathrooms. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the school office and will use the staff restroom if necessary. Report continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Lea Habtom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CREEKSIDE OAKS ELEMENTARY PRESCHOOL	FACILITY NUMBER: 313624423
	VISIT DATE: 07/31/2025

NARRATIVE

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OUTDOOR ACTIVITY SPACE:
A waiver request was submitted requesting shared use of the Transitional/ Kindergarten playground. Applicant understands that the preschool children may not use the playground at the same time as the kindergarten students. Measurements for the outdoor play area was not taken during today's inspection. The outdoor play area will remain the same as previously used in room K1. Measurements of the outdoor play area was based on measurements taken on August 4, 2022, inspection. The outdoor play area contains a total of 6398 square feet, which will accommodate the applicant's request for 24 preschool children. The outdoor play areas is fenced and is equipped with age-appropriate equipment. There are shaded areas supplied by trees and awnings. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

This facility plans to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Child Care Center Sections 101173 and 101226. A Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 513-0301 (voice)/(800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA available at: http:www.ada.gov/childqanda.ht

The applicant was encouraged to visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to child care centers.

LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates.

Effective July 31, 2025, the facility is granted to serve 24 preschool children, ages 2-5, in room 9.

There were no deficiencies cited during today's visit. Notice of Site Visit provided. Exit interview conducted and report was reviewed with the facility representative, Daniel Mendoza.

NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Lea Habtom
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025

LIC809 (FAS) - (06/04)

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