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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343625410
Report Date: 04/21/2025
Date Signed: 04/21/2025 11:33:58 AM

Document Has Been Signed on 04/21/2025 11:33 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:LIL' SCHOOLFACILITY NUMBER:
343625410
ADMINISTRATOR/
DIRECTOR:		DORAN, CELESTEFACILITY TYPE:
860
ADDRESS:8089 MADISON AVENUE #11TELEPHONE:
(916) 962-2137
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY: 135TOTAL ENROLLED CHILDREN: 135CENSUS: 14DATE:
04/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Celeste DoranTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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On April 21, 2025, Licensing Program Analyst (LPA), met with director Celeste Doran at approximately 9am, for the purpose of a case management visit. Upon arrival LPA toured the infant room and counted 4 infants in the 0-to-12-month room, with two teachers, and 14 in the 12 months to 24-month room with four teachers.

LPA toured the infant room and viewed the infant refrigerator, which serves both infant rooms. LPA observed all infant bottles labeled with names in their own baskets. LPA also observed the bottles with breast milk were identified by a red strip. Further children were assigned a colored tape strip with their name written on it. Through interviews with the area manager, director and infant staff, LPA found there was an incident that occurred, when a bottle was in the warmer, and the name had rubbed off when placed inside. At the time, the bottle was placed in the warmer by the assistant director (from another facility), who was aware of which child’s bottle it was. A new teacher in training, retrieved the bottle and did not confirm the bottle to the child, before feeding the child. After the feeding, staff found that the new teacher did not follow protocol, and that a child had been fed the wrong bottle. The parents of the children involved were contacted immediately.

This resulted in a personal rights violation which is documented on the 809-D page.

This report was reviewed with the director, Celeste Doran, appeal rights provided and a notice of site visit will be posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Michelle Perez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/21/2025 11:33 AM - It Cannot Be Edited


Created By: Michelle Perez On 04/21/2025 at 11:00 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LIL' SCHOOL
FACILITY NUMBER: 343625410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2025
Section Cited
CCR
101223(a)(2)

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Personal rights, infants- The licensee shall ensure that each child is accorded the following personal rights. To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs
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Director will reinforce training of staff through additional bottle feeding observations and provide a letter to LPA outlining this policy, by the POC date.
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This was not evidenced by: LPA found staff accidently fed the wrong bottle to another infant.
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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.
Mai Lor
NAME OF LICENSING PROGRAM MANAGER:
Michelle Perez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2025


LIC809 (FAS) - (06/04)
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