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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313624423
Report Date: 01/12/2026
Date Signed: 01/12/2026 11:05:33 AM

Document Has Been Signed on 01/12/2026 11:05 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 PRESCHOOLFACILITY NUMBER:
313624423
ADMINISTRATOR/
DIRECTOR:		AIMEE BOUCHERFACILITY TYPE:
850
ADDRESS:2030 1ST STTELEPHONE:
(530) 745-1380
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 10DATE:
01/12/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:10 AM
MET WITH:Nora RodvoldTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On January 12, 2026, an unannounced annual/random inspection was made by Licensing Program Analyst (LPA) Lea Habtom. LPA Habtom met with designated representative Nora Rodvold. At the time of arrival, there were 10 preschool children being supervised by 3 staff. The preschool is located on the Creekside Oaks Elementary School campus in Room 9. The program provides two part-time programs Monday- Friday from 8:00 am- 11:00 am and 12:00 pm- 3:00 pm.

The following areas are in compliance during inspection: There are no bodies of water. Firearms and ammunition are not on the premises. There are no poisons on the premises. Disinfectants, hazardous items and medications are inaccessible to children. Furniture and equipment are sufficient, age appropriate and in good repair. The facility share the use of the elementary school playground. There is a shared bathroom & playground waiver. Classroom is safe and clean. Carbon Monoxide detector is on the premises. Storage containers for solid waste are covered. Drinking water is available both indoors and outside. There is a water fountain in the classroom. Children have their own labeled water bottles for both indoor & outdoor. Snack menus are posted. The facility provides an AM and PM snack. Children do not nap. The facility is in compliance with conditions and limitations specified on the license. Teacher/child ratios are maintained and adequate supervision is being provided during this inspection. There is adequate space for children belongings. All waivers are being followed.

Criminal record clearances and/or exemptions are completed by Placer County Office of Education (PCOE). Facility representative was reminded that all adults 18 and over, 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 Child Care Center. 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. First Aid/CPR reviewed and in compliance. Emergency information reviewed for some children. Staff records reviewed. Children files reviewed.
LPA observed proof that all staff/ volunteers have met the requirements of SB 792.

LPA observed that all staff has completed the required mandated reporter training (AB 1207) at website: www.mandatedreporterca.com

Report continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Lea Habtom
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2026
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: 01/12/2026
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LPA provided the Community Care Licensing website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current in regards to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws childcareadvocatesprogram@dss.ca.gov.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (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.htm

No deficiencies observed in the areas inspected during today's inspection.
A notice of site visit was provided to be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal rights provided.

Exit interview conducted and report was reviewed with the facility representative Nora Rodvold.

NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Lea Habtom
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2026
LIC809 (FAS) - (06/04)
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