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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500446
Report Date: 08/22/2024
Date Signed: 08/22/2024 02:16:12 PM

Document Has Been Signed on 08/22/2024 02:16 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:FORTUNE PRESCHOOLFACILITY NUMBER:
344500446
ADMINISTRATOR/
DIRECTOR:		MICHELLE ROYFACILITY TYPE:
850
ADDRESS:9424 BIG HORN BOULEVARDTELEPHONE:
(916) 793-3671
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 84TOTAL ENROLLED CHILDREN: 84CENSUS: 17DATE:
08/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Desiree LaraeTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 08/22/2024, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit to the facility for the purpose of a Case Management inspection. LPA arrived at the center and observed that Director Roy (D1) was not present. LPA was granted entrance into the facility. LPA was instructed to work with acting Site Supervisor Desiree Hodge (D2). LPA disclosed the purpose of the inspection. LPA conducted a tour of the facility during nap time and observed 17 preschool aged children being supervised by D2 and 3 staff members. LPA determined, through accessing Guardian, that 1 staff member was not associated to the license. LPA observed the individual caring for and supervising children.
This posed an immediate risk to the health and safety of children in-care. A Type-A deficiency was cited on a subsequent 809-D page and a Civil Penalty was assessed. D2 understands that all parents or authorized representatives of currently enrolled children must sign the LIC 9224 form and be available to the Department for review. D2 understands that parents or authorized representatives of children enrolling for up to one year must sign the LIC 9224 form and be available to the Department for review. D2 acknowledged that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809-D with Type A deficiencies for 30 days.

An exit interview was conducted, and the report was reviewed with Site Supervisor Hodge. LPA provided Licensee Appeal Rights to D2. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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 08/22/2024 02:16 PM - It Cannot Be Edited


Created By: Katy Velazquez On 08/22/2024 at 01:46 PM
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: FORTUNE PRESCHOOL
FACILITY NUMBER: 344500446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
CCR
101216(i)(2)

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(i) Prior to employment or initial presence in the child care center, all employees and volunteers subject to a criminal record review shall:...
(2) Request a transfer of a criminal record clearance as specified in Section 101170(f)...This requirement was not met

(3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 101170.1(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.
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Desiree Hodge will complete a Transfer Request. LPA will associate Desiree Hodge to the facilty's license while on site. LPA will provide a letter of clearance.
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as evidenced by LPA observing Desiree Hodge providing care and supervision to children on 08/22/2024. Record review revealed that Desiree Hodge was not associated to the facilty. This poses/posed an immediate 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:Karyn Guerra
LICENSING EVALUATOR NAME:Katy Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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