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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340318296
Report Date: 05/04/2023
Date Signed: 05/04/2023 01:03:18 PM

Document Has Been Signed on 05/04/2023 01:03 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:HAGGINWOOD STATE PRESCHOOLFACILITY NUMBER:
340318296
ADMINISTRATOR:SYMON, TANISHAFACILITY TYPE:
850
ADDRESS:1418 PALO VERDE AVENUE, RM. 20TELEPHONE:
(916) 566-3475
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: DATE:
05/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Christine BellucciTIME COMPLETED:
01:15 PM
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At 11:00 a.m. on Thursday, May 4th, 2023, Licensing Program Analyst (LPA) Karyn Guerra met with TOSA, Christine Bellucci, for the purpose of an unannounced, required - 1 year inspection. No children were present upon arrival, as the program was on a break between a.m. and p.m. classes. Children arrived to the facility at 12:00 p.m. Following lunchtime, a census of 10 children supervised by 2 staff was observed. The program operates in classroom 20 from 8:00 a.m.-11:00 a.m., and 12:00 p.m. - 3:00 p.m. and receives state funds.

Criminal record clearance is on file with Twin Rivers Unified School District. TOSA 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. LPA discussed association of substitutes from outside agencies.

LPA conducted a health and safety inspection of the classrooms, restrooms, and food service areas. LPA observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, car seat laws, menus, and daily schedule. Cleaning disinfectants and hazardous items are appropriately stored and inaccessible to children. TOSA stated that there are no firearms nor poisons on the premises. Carbon monoxide detectors are hardwired into the alarm system. Fire Drills were conducted and documented at least once every 6 months.

The facility provides breakfast or lunch. Bins for solid waste have tight fitting lids. The floors appeared clean throughout the facility. Food is all prepared in the cafeteria. Drinking water is provided to children via water cooler and cups. Lead testing of drinking water has been conducted. An electronic system is used for sign in and sign out. LPA observed full legal signature of parent/guardians.

Report continued on 809-C.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: HAGGINWOOD STATE PRESCHOOL
FACILITY NUMBER: 340318296
VISIT DATE: 05/04/2023
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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 Child Care Centers Sections 101173 and 101226. 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.

LPA conducted a health and safety inspection of the outdoor space. Playground equipment and surfaces were free of loose or sharp parts. LPA observed foam wood chips beneath the play structure. Outdoor shade was provided by canopies. Water is accessible via drinking fountains.

LPA reviewed staff and children's records. Children's records are centrally stored in the school office. Staff records are centrally stored in the district office. Each child's file contained an admission agreement, emergency card, health history, immunization record, and acknowledgement of receipt for personal rights, consent for emergency medical treatment, and parent’s rights and physician reports. LPA observed current CPR and First aid certification all staff. LPA observed staff immunization records, current AB 1207 Mandated Reporter training certificates, employee rights, and documentation of the educational background, training, and/or experience.

A staff interview was conducted with TOSA, Christine Bellucci.

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.

In the areas that were evaluated, no deficiencies were cited during today’s inspection. Exit interview conducted and report was reviewed with the TOSA, Christine Bellucci. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Karyn Guerra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC809 (FAS) - (06/04)
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