343623182-10-25-2022-03-CC-ATIY-CKJNLM-20221025103347

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343623182
Report Date: 10/25/2022
Date Signed: 10/25/2022 10:34:22 AM

Document Has Been Signed on 10/25/2022 10:34 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 BRET HARTE HEAD START		FACILITY NUMBER:	343623182
ADMINISTRATOR:	XAYAVONG, SAMANTHA		FACILITY TYPE:	850
ADDRESS:	2761 9TH AVENUE		TELEPHONE:	(916) 263-3800
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95818
CAPACITY: 48	TOTAL ENROLLED CHILDREN: 48	CENSUS: 18	DATE:	10/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	XAYAVONG, SAMANTHA		TIME COMPLETED:	10:50 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On October 25, 2022, at approximately 8:30 AM, Licensing Program Analysts (LPAs) Alize Tillery and Matt Gallo met with Director Samantha Xayavong for the purpose of an unannounced required 1 year annual inspection. Upon arrival, LPA observed 5 toddler children, supervised by 2 staff and 13 preschool children supervised by 3 staff. The facility hours of operation are Monday through Friday from 8:00 AM to 5:00 PM. The facility does not offer transportation services.

LPAs toured all activity and classroom spaces (Toddler classroom and Preschool classroom), restrooms and outdoor play area. LPAs observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster and daily schedule. Cleaning disinfectants, medications and hazardous items are appropriately stored and inaccessible to children. Director stated there are no poisons or firearms on the premises. Furniture and equipment are in good condition. Toileting facilities are in safe and sanitary condition; one toilet out of four, is out of service. Director stated that they have contacted Sac City and requested maintenance. Floor rugs appeared to be stained and with accumulated debris and dirt, throughout the facility. LPAs observed a functional carbon monoxide detector, smoke detector and fire extinguisher. LPA discussed COVID19 guidelines with Director.

The program provides breakfast, lunch and pm snack. LPAs observed trash bins with tight fitted lids. Drinking water is readily available to children both indoors and outdoors. Director stated that they use paper cups and use the water source in the preschool classroom to fill water pitchers. LPAs observed the facility’s electronic sign in and out system. Facility has record of conducting fire drills at least every six months; last fire drill was conducted on 10/14/2022. Playground equipment and surfaces are free of loose or sharp parts. There are sufficient equipment and toys, and there are shaded areas supplied by the buildings and trees and a tent, and there is bark under the play structure for cushioning.

Report continues on 809-C.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

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 3

Document Has Been Signed on 10/25/2022 10:34 AM - It Cannot Be Edited

Created By: Alize Tillery On 10/25/2022 at 10:02 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 BRET HARTE HEAD START	FACILITY NUMBER: 343623182
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238.3(b)

Indoor Activity Space

(b) The floors of all rooms shall have a surface that is safe and clean. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that the floor rugs throught out the facility observed to have built up debris/dirt, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2022
	Plan of Correction
1 2 3 4	Director will submit proof to LPA Tillery of conducting deep clean of the rugs in classrooms.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Alize Tillery

LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 BRET HARTE HEAD START	FACILITY NUMBER: 343623182
	VISIT DATE: 10/25/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

5 staff and 8 children records were reviewed. Staff files were observed to be complete and included: Education Verification, LIC 501 Personnel Record, LIC 503 Health Screenings, LIC 508 Criminal Record Statements, LIC 9052 Employee Rights, Immunizations (Tdap, MMR, Influenza) and current Mandated Reporter training certificates. At least one staff member present today has a current Pediatric CPR and First Aid certification that expires in 08/2024.

Children Files were also observed to be complete and included: Admission Agreements, Physician and Parent Health History Reports, Emergency Cards, Consent for Medical Treatment forms, Personal and Parent Rights Forms, and immunizations. LPA observed a current Children’s Roster. LPA reminded Licensees that 100% supervision is required at all times. LPA reviewed the Department's inspection authority and discussed with designee any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within ten working days.

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/process.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA is provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A deficiency is cited on the following 809D page.

A notice of site visit was given and must remain posted for 30 days. An exit interview was conducted and the report was reviewed with the Director, Samantha Xayavong.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3