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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343616736
Report Date: 03/22/2024
Date Signed: 03/22/2024 10:55:34 AM


Document Has Been Signed on 03/22/2024 10:55 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:CALVARY CHRISTIAN PRESCHOOLFACILITY NUMBER:
343616736
ADMINISTRATOR:ARRIAGA, SUSANFACILITY TYPE:
850
ADDRESS:4911 47TH AVENUETELEPHONE:
(916) 393-3633
CITY:SACRAMENTOSTATE: CAZIP CODE:
95824
CAPACITY:40CENSUS: 19DATE:
03/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Susan ArriagaTIME COMPLETED:
11:15 AM
NARRATIVE
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On 3/22/2024, Licensing Program Analyst (LPA) Amanda Sutter arrived at the facility for the purpose of a case management inspection. While at the facility, LPA learned that a child had attended the facility without the facility obtaining an immunization record. Through interview, LPA learned that the child had not been immunized.

A notice of site visit was given and must remain posted for 30 days. Based on the inspection, one type B citation has been issued. Exit interview conducted and report was reviewed with Director Susan Arriaga.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Amanda SutterTELEPHONE: (916) 261-8918
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
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 03/22/2024 10:55 AM - It Cannot Be Edited

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: CALVARY CHRISTIAN PRESCHOOL
FACILITY NUMBER: 343616736

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2024
Section Cited
CCR
101220.1(a)

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101220.1 Immunizations (a) Prior to admission to a child care center, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, commencing with Section 6000.
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LPA observed the child's file and verified that the child has been disenrolled from the facility. LPA provided Director with Title 22 regulations 101220.1 and Shots For Schools exemption information page. Director to provide written verification that she has read and understands the regulations.
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This requirement is not met as evidenced by:

Based on record review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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 LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Amanda SutterTELEPHONE: (916) 261-8918
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2