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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343608220
Report Date: 07/30/2024
Date Signed: 10/22/2024 11:06:03 AM

Document Has Been Signed on 10/22/2024 11:06 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MERRYHILL SCHOOL - HARBOUR POINTFACILITY NUMBER:
343608220
ADMINISTRATOR/
DIRECTOR:		STEPHANIE GILLFACILITY TYPE:
830
ADDRESS:9561 HARBOUR PT. DRIVETELEPHONE:
(916) 683-3244
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 21DATE:
07/30/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Stephanie GillTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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This is an AMENDED version of the original report to amend the D-PAGE.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/22/2024 11:06 AM - It Cannot Be Edited


Created By: Katy Velazquez On 10/22/2024 at 10:37 AM
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: MERRYHILL SCHOOL - HARBOUR POINT
FACILITY NUMBER: 343608220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101430(a)(3)(A)(4)(a)
Infant Care Activities
(A) Staff shall place infants up to 12-months of age on their backs for sleeping. (4) Infants with an Individual Infant Sleeping Plan [LIC 9227 (3/20)] that have Section C of the form completed and signed by an authorized representative shall be placed on their back when first laid down to sleep. In the event the infant changes position, the infant may remain in the alternative position. (a) Upon staff observation that the infant is capable of rolling from their back to their stomach and stomach to their back, the provider shall fill out Section D of the Individual Infant Sleeping Plan [LIC 9227 (3/20)], notify the authorized representative, and obtain the authorized representative's signature on the individual sleeping plan no later than the next business day following observation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA 07/30/2024 observation and record review, the licensee did not comply with the section cited above when an infant was observed to be sleeping on his/her stomach, and the Individual Sleep Plan did not provide parent proof of infant's ability to roll, this poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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LPA was able to clear this citation while on field visit as this is an amended D page and the POC was already provided to LPA.

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:Karyn Guerra
LICENSING EVALUATOR NAME:Katy Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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