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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343609860
Report Date: 09/23/2022
Date Signed: 09/23/2022 01:03:39 PM

Document Has Been Signed on 09/23/2022 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:TSA AFTER SCHOOL PROGRAMFACILITY NUMBER:
343609860
ADMINISTRATOR:BUCSKO, JO ANNEFACILITY TYPE:
840
ADDRESS:2540 ALHAMBRA BLVD.TELEPHONE:
(916) 469-4630
CITY:SACRAMENTOSTATE: CAZIP CODE:
95817
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 0DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Leonel GutierrezTIME COMPLETED:
01:15 PM
NARRATIVE
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On September 23, 2022 at approximately 10:45 AM, Licensing Program Analyst (LPA) Josiah Gathing met with Director Leonel Gutierrez and Assistant Director Jeretha Miller for the purpose of an unannounced annual random inspection. The facility operates an after school program, and no children had arrived at the time of today’s inspection. The facility hours of operation are Monday through Friday from 3:00 PM to 6:00 PM.

LPA toured the indoor classroom areas, children’s restrooms, and outdoor play area. Director stated there are no poisons or firearms on the premises. Toxic and hazardous items are inaccessible to children. Furniture and equipment are in good condition. Playground equipment and surfaces are free of loose or sharp parts. Restrooms are in sanitary condition with functioning toilets. The floors were clean throughout the facility.

LPA observed that solid waste containers were covered. Per Assistant Director, the facility provides snacks for the children. Drinking water was readily available to children both indoors and outdoors. LPA observed a manual sign in and out sheet with parent’s full signatures.

According to Director, staff files were stored in the Human Resources office, which was locked and unavailable during today’s inspection. LPA observed children’s documents and reminded Assistant Director to ensure that all Parents Rights and Personal Rights documents were signed and stored in each child’s folder. LPA observed a current children’s roster and reminded Assistant Director to document fire drills at least once every six months. The facility is equipped with First Aid equipment.

Report continues on LIC809-C...

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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 09/23/2022 01:03 PM - It Cannot Be Edited


Created By: Josiah Gathing On 09/23/2022 at 12:43 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: TSA AFTER SCHOOL PROGRAM
FACILITY NUMBER: 343609860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as staff files were not accessible during today's inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2022
Plan of Correction
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Facility will make staff files available for LPA review by the above POC date. Facility will ensure that copies of staff files are available for future Licensing inspections.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Seychelle De Luca
LICENSING EVALUATOR NAME:Josiah Gathing
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022


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: TSA AFTER SCHOOL PROGRAM
FACILITY NUMBER: 343609860
VISIT DATE: 09/23/2022
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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/inspection-process.

Assistant Director was encouraged to the visit the Department's website at WWW.CCLD.CA.GOV for information regarding child care updates, PINs, forms, regulations and legislation pertaining to child care centers. Exit interview was conducted and report was reviewed with the Director. A notice of site visit was given and must remain posted for 30 days.

A deficiency is cited on the following LIC809-D. Appeal Rights were provided.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC809 (FAS) - (06/04)
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