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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343602581
Report Date: 07/26/2024
Date Signed: 07/26/2024 02:31:08 PM

Document Has Been Signed on 07/26/2024 02:31 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ANTELOPE CHRISTIAN ACADEMY PRESCHOOLFACILITY NUMBER:
343602581
ADMINISTRATOR/
DIRECTOR:		CAROLYN HEWETTFACILITY TYPE:
850
ADDRESS:4533 ANTELOPE ROADTELEPHONE:
(916) 722-6169
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 7DATE:
07/26/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Cheryl RamirezTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst Erwina Pascual-Golamco and Loraine Perez (LPA) met with Director Cheryl Ramirez for the purpose of a case management inspection. The purpose of today's inspection was explained. LPAs observed 7 children in care with the Director and 1 staff, that was not associated to the facility. LPAs reviewed staff files and did not observe a transfer request form LIC9182.

Director was reminded that all individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility…
(2) Request a transfer of a criminal record clearance as specified in Section 101170(f)…
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.

A civil penalty is being assessed in the amount of $500 for the maximum of five days for Clearance Transfer for 1 individual.



Based on today's inspection and record review, one Type A deficiencies have been issued on the attached LIC809-D page. Director shall provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. Exit interview was conducted with Director, appeal rights were provided, and A notice of site visit was given to the Director, who will post it where visible to parents/guardians for 30 days. A signed Acknowledgement of Receipt of the Licensing Report (LIC 9224) must be placed in the child's file for verification.
SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Loraine Perez
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2024
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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Document Has Been Signed on 07/26/2024 02:31 PM - It Cannot Be Edited


Created By: Loraine Perez On 07/26/2024 at 01:20 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANTELOPE CHRISTIAN ACADEMY PRESCHOOL
FACILITY NUMBER: 343602581

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/29/2024
Section Cited
CCR
101170(e)(2)

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101170(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:…(2) Request a transfer of a criminal record clearance as specified in Section 101170(f)…
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Director stated with new or returing staff background clearance will be complete before start date.
LPA sassisted in transfer background clearance, associating staff to this facility at the time of inspection.Deficiency cleared at time of visit.
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This requirement was not met as evidenced by:
Based on record review staff was not associated with this facility at the time of hire.
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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:Amanda Blesi
LICENSING EVALUATOR NAME:Loraine Perez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024


LIC809 (FAS) - (06/04)
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