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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622573
Report Date: 09/21/2021
Date Signed: 09/21/2021 10:31:41 AM

Document Has Been Signed on 09/21/2021 10:31 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
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) 593-5169
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY: 76TOTAL ENROLLED CHILDREN: 0CENSUS: 42DATE:
09/21/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Joua XiongTIME COMPLETED:
10:45 AM
NARRATIVE
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On September 21, 2021 at 9:30 AM, Licensing Program Analyst Tanya Washington met with Site Supervisor, Joua Xiong for an unannounced case management inspection.
LPA toured the facility inside and out and observed 13 staff supervising 16 toddlers and 26 preschool children in 4 different classrooms.

Facility self reported an unusual incident which occurred on 08/31/2021. It was reported that during a practice fire drill Child #1 was left behind in the classroom for approximately one minute as the rest of the class was transitioning to a designated meeting area outside. A staff member who was in charge of doing a final walk through noticed Child #1 safely standing in the middle of the classroom. Per staff Child #1 was left without direct visual supervision for approximately one minute.

Staff #1 escorted Child #1 outside to be with the classroom. At the end of the practice fire drill staff reviewed the transition log, did a head count of children and escorted children back to their designated classrooms.

Since the incident, management held an all staff meeting to ensure that staff conduct a head count as well as do a roll call and ensure that children are closely monitored at all times.

Upon receipt, facility representative shall post and provide copies of this licensing report to parents/ guardians of children who are currently enrolled as well as parents/ guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must acknowledge receipt of this report and citation by signing a LIC9224, “ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS”. A copy of this form should be placed in each child file upon receipt from parent.

LPA discussed this report with facility representative and conducted an exit interview. LPA also provided appeal rights. Notice of site visit posted.

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Tanya Washington
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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 09/21/2021 10:31 AM - It Cannot Be Edited


Created By: Tanya Washington On 09/21/2021 at 10:08 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: SETA - 16TH AVENUE HEAD START
FACILITY NUMBER: 343622573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2021
Section Cited
CCR
101229.1

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No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Facility management had a meeting with all staff regarding head counting and roll call during transitions. LPA obtained a copy of signed meeting agenda by all staff. This deficiency is cleared as of today.
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This requirement is not met as evidenced: Facility self reported that Child #1 was left behind in the classroom for approximately one minute during a practice fire drill.
This is an immediate risk to the health and safety of children 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:Roxana Saravia
LICENSING EVALUATOR NAME:Tanya Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021


LIC809 (FAS) - (06/04)
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