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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313627079
Report Date: 06/24/2026
Date Signed: 06/24/2026 11:58:48 AM

Document Has Been Signed on 06/24/2026 11:58 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:APPLE BLOSSOM ACADEMYFACILITY NUMBER:
313627079
ADMINISTRATOR/
DIRECTOR:		FITZHUGH, JESSICAFACILITY TYPE:
860
ADDRESS:18018 APPLEGATE RDTELEPHONE:
(530) 401-4182
CITY:APPLEGATESTATE: CAZIP CODE:
95703
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 0DATE:
06/24/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Jackie FitzhughTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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At 9:00am on 6/24/2026, Licensing Program Analyst (LPA) Matthew Gallo and Licensing Program Manager (LPM) Mai Lor met with Applicant Jackie Fitzhugh for the purpose of a Prelicensing Inspection. Administrator Angela Rodrigues-Webster and Kurt Fitzhugh were also present for the inspection. Prior to the visit, Applicant had requested a toddler component for 8 toddlers aged 18-36 months and a preschool component for 12 preschool children aged 2 years until entry into kindergarten. During the visit, Applicant stated their interest in changing their request to include only a preschool component to serve 22 preschool children aged 2 years until entry into kindergarten. Updated fire clearance will be required. The program will operate 7:00am to 6:00pm, Monday-Friday, year-round. The facility will provide breakfast and AM&PM snacks, while parents will provide lunch.

LPA reviewed with applicant the LIC 311A, Records to be Maintained at the Facility, for child’s records, personnel records, administrative records, and documents to be posted. Entrance Checklist was provided to the applicant.

INDOOR ACTIVITY SPACE:
There are 2 preschool classrooms located in the facility. LPA observed a sufficient amount of equipment, toys, tables, chairs, cubbies, and napping cots. There is a first aid kit located in the teacher prep space. Medications will be stored and inaccessible to children. LPA observed cleaning disinfectants are stored in low cabinets in the kitchen, which are accessible to the the area that will be used to isolate sick children. Safety locks are or a barrier is required to make disinfectants inaccessible. Applicant stated there are no poisons or firearms on the premises, and acknowledges that any poisons must be made inaccessible by key or combination lock. Applicant stated the facility will utilize water bottles of filtered water for drinking water. Applicant stated that they will use an electronic sign-in/sign-out system Report continues on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Matthew Gallo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2026
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: APPLE BLOSSOM ACADEMY
FACILITY NUMBER: 313627079
VISIT DATE: 06/24/2026
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LPA measured the preschool classrooms. The total classroom space contains a total of 1,358.30 square feet, which will accommodate the requested updated capacity of 22 preschool children. There are 2 toilets and 2 sinks for the children, and a separate private restroom for the staff. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the teacher preparation space and will use the staff restroom, if necessary.

OUTDOOR ACTIVITY SPACE:
The outdoor play area is fenced with a wrought iron fence. In areas where the fence rests on top of a concrete retaining wall bordering the parking lot, the fence is not 4 feet tall from a standing vantage point.
LPA observed a sufficient amount of age appropriate equipment and toys. LPA did not observe a permanent play structure. There are no bodies of water on the premises. There are shaded areas supplied by a shade cover. LPA observed functioning outdoor water fountain.

LPA measured the preschool outdoor activity space. The outdoor play area contains a total of 1,714 square feet, which will accommodate Applicant’s request for 22 preschool children. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

Applicant will wait until facility opens to determine IMS needs. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated 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) 514-0301 (voice) or (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.

LPA discussed the following: 100% supervision is required at all times; personal rights; inspection authority; reporting requirements; staff to children ratios and capacity; staff qualifications; and maintaining buildings and grounds. LPA discussed with Applicant any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

Report continues on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Matthew Gallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: APPLE BLOSSOM ACADEMY
FACILITY NUMBER: 313627079
VISIT DATE: 06/24/2026
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Applicant was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test as specified in Health and Safety Code section 1597.16. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP.). LPA referred applicant to the Department website for lead: Lead Toxicity Prevention and Water Testing Information (https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information).

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters, and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/communitycare-licensing/subscribe and select the Child Care option to receive email communication.

If you have any questions regarding the process or CARE tools, please send email inquiries 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/inspection-process. Report continues on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Matthew Gallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: APPLE BLOSSOM ACADEMY
FACILITY NUMBER: 313627079
VISIT DATE: 06/24/2026
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Exit interview conducted and report was reviewed with the facility representatives, Kurt Fitzhugh and Angie Rodrigues-Webster.

The following items are required before a license will be issued:


-An updated LIC200A with a requested capacity of 22 preschool children.
-Updated Facility Sketches, Parent Handbook, LIC500 Personnel Report, Admission Agreement, LIC401 Monthly Operating Statement, LIC610 Emergency and Disaster Plan, reflecting a preschool component only
-The outdoor area fence must be 4 feet tall from all standing vantage points in the yard
-Cabinets storing disinfectants must be made inaccessible
-Financial verification to verify approximately three months of operating budget- facility may submit bank statements under the corporation name
-Amended fire clearance to reflect the updated age component and capacity
-Proof of carbon monoxide detector
NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Matthew Gallo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2026
LIC809 (FAS) - (06/04)
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