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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622573
Report Date: 07/27/2021
Date Signed: 07/27/2021 12:50:23 PM

Document Has Been Signed on 07/27/2021 12:50 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:SETA - 16TH AVENUE HEAD STARTFACILITY NUMBER:
343622573
ADMINISTRATOR:JOUA XIONGFACILITY TYPE:
850
ADDRESS:4104 MARTIN LUTHER KINGJR BLVDTELEPHONE:
(916) 263-3804
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY: 76TOTAL ENROLLED CHILDREN: 0CENSUS: 35DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Joua XiongTIME COMPLETED:
12:55 PM
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On Tuesday, July 27th, 2021, at 11:15 AM, Licensing Program Analyst (LPA) Tanya Washington met with the Site Supervisor, Joua Xiong and Program Officer, Lynda De La Mora, for the purpose of an unannounced Annual Required inspection. LPA observed care and supervision of 26 preschool children and 9 toddler age children supervised by adequate amount of staff in separate rooms and outdoors.

Operating hours are 8:00 AM to 4 PM Monday through Friday. The facility operates year around.

At 11:30 AM, LPA initiated a health and safety inspection of all indoor and outdoor areas accessible to children. LPA observed that hazardous items (disinfectants, cleaning solutions, etc.) were inaccessible to children in care.

LPA inspected the food service area and observed that the food products appeared to be protected against contamination. Facility serves breakfast, lunch and PM snack to children. Each meal is individually wrapped in saran wrap and served to children on a disposable plate. Site Supervisor stated that due to COVID19, the parents do not enter the facility and have access to the monthly menu through SETA app and also receive a copy of it in their e-mail.

LPA reviewed care and supervision of children, staffing ratios, health related services (including medications and first aid supplies), furniture, equipment, and fire drills logs. LPA observed all required forms to be posted. Facility utilizes electronic sign in/out system.

Drinking water is readily accessible to children in care inside and outside of the building, facility utilizes a pitcher and disposable paper cups. LPA observed sinks and toilets to be operable. There are adequate toys, equipment, and supplies available for the children. The outdoor play area was observed to have adequate cushioning material and play equipment to be in safe condition. Shaded areas are also available for the children in care.

*Continued on LIC 809-C
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2021
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
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: SETA - 16TH AVENUE HEAD START
FACILITY NUMBER: 343622573
VISIT DATE: 07/27/2021
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*Continuation of LIC 809

At 12:05 PM, LPA began to review children’s and staff's files. All staff currently employed with the facility have health screening reports with TB test, immunizations, and Mandated Reporter training. Program Officer provided verification of enrollment for staff who are scheduled to renew their CPR and First Aid certification.

LPA provided the Lead Testing brochures (AB 2370) and discussed the current Covid-19 protocols and guidelines.

LPA provided the Licensing Agency website (ccld.ca.gov), so the Site Sueprvisor may obtain updated licensing information, regulations, and forms.



Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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 for TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the Americans with Disabilities Act, available at: http://www.ada.gov/childqanda.htm

At 12:45 PM, LPA reviewed the report and an exit interview was conducted.

LPA provided a Notice of Site Visit and the Site Supervisor acknowledges that this notice shall remain posted for 30 days for parental review.



The Site Supervisor's signature on this form acknowledges receipt of this report and said documents.
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
LIC809 (FAS) - (06/04)
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