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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500637
Report Date: 06/29/2023
Date Signed: 06/29/2023 09:58:24 AM

Document Has Been Signed on 06/29/2023 09:58 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MIWOK VILLAGE ELEMENTARY SCHOOLFACILITY NUMBER:
344500637
ADMINISTRATOR:JODI BOYLEFACILITY TYPE:
850
ADDRESS:10070 LOUSADA DRIVETELEPHONE:
(916) 831-2091
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 24TOTAL ENROLLED CHILDREN: 15CENSUS: 0DATE:
06/29/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tabitha ThompsonTIME COMPLETED:
10:30 AM
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Application Specialist (AS) Alecia Sifuentes and Licensing Program Analyst (LPA) Corina Beckby met with Licensee Representative (LR) Tabitha Thompson for the purpose of a case management inspection. Licensee requests a room change. Licensee is not making any changes to the capacity. The preschool program is located at Miwok Village Elementary School. The program currently operates Monday through Friday from 8:00 a.m. to 3:30 p.m.

INDOOR ACTIVITY SPACE:
There is one preschool classroom located in room L12. AS observed a sufficient amount of equipment, toys, tables, chairs, and cubbies. AS measured room L12. The total classroom space contains a total of 866 square feet, which will accommodate the current licensed capacity of 24 preschool children. There are one toilet and two sinks for the children. AS observed a Shared Bathroom Waiver on file. There is a separate private restroom for the staff. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

Licensee 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 notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Licensee Representative, Tabitha Thompson.

The following item is required before AS will approve the room change:
1. Updated granted fire clearance (STD850)
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2023
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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