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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500637
Report Date: 08/30/2024
Date Signed: 10/02/2024 01:23:16 PM

Document Has Been Signed on 10/02/2024 01:23 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:MIWOK VILLAGE ELEMENTARY SCHOOLFACILITY NUMBER:
344500637
ADMINISTRATOR/
DIRECTOR:		JODI BOYLEFACILITY TYPE:
850
ADDRESS:10070 LOUSADA DRIVETELEPHONE:
(916) 831-2098
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 24TOTAL ENROLLED CHILDREN: 44CENSUS: 0DATE:
08/30/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Sherlyn WarnerTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On August 30, 2024, Licensing Program Analyst (LPA) Corina Beckby met with Substitute Certificated Teacher, Sherlyn Warner, for an unannounced required annual random inspection. LPA observed 2 teachers supervising no preschool children. Hours of operation are M-Th 8:00 am to 11:30 am and M-F 12:15-3:15 pm. Annual fees have not been paid.

LPA inspected all activity and classroom spaces, restrooms, food service, and outdoor play areas. Hazardous items are inaccessible to children. Furniture and equipment are in operable and safe condition. Playground equipment and surfaces are free of loose or sharp parts, and adequate cushioning was observed in areas underneath climbing equipment. Toileting facilities are in safe, sanitary, and operating condition. The floors appeared clean throughout the facility. The food preparation space is free of litter and all food was protected against contamination. Storage containers with solid waste have tight-fitting covers in each classroom. Medications are stored in a central location. Two children in care require medications.

Breakfast and Lunch are provided by the school district. LPA observed posted menus showing planned meals at least one week in advance. Noncontaminated Drinking water is readily available to children both indoors and outdoors.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA referred Facility Representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.


Continued on LIC 809-C...
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 10/02/2024 01:23 PM - It Cannot Be Edited


Created By: Corina Beckby On 08/30/2024 at 11:20 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: MIWOK VILLAGE ELEMENTARY SCHOOL
FACILITY NUMBER: 344500637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 4 out of 6 staff members were missing Mandated Reporter Certificates, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Facility Representative will email copies of certificates to LPA by due date.
Type B
Section Cited
CCR
101212(b)
Reporting Requirements
(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that the department was not notified of the Directors absence and an ECE qualified Director packet was not submitted for acting Director, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Licensee will email LPA the packet for a qualified acting Director with ECE qualifications, by due date.
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:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SCHOOL
FACILITY NUMBER: 344500637
VISIT DATE: 08/30/2024
NARRATIVE
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LPA observed full legal signatures while reviewing the sign in and sign out sheet. LPA reviewed records for all staff. Current Pediatric CPR and First Aid certification which expires 08/14/26. All staff currently employed with the facility have: a criminal record clearance, a health screening report, immunization records, documentation of their educational background, training, and/or experience. LPA observed 2 of 6 AB1207 mandated reporter training certificates for staff. The facility was reminded to renew the course every 2 years through www.mandatedreporterca.com website. 10 Children records were reviewed. Each child's file contained a completed emergency contact form, immunization records, signed personal rights form, and a completed medical assessment.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

All individuals subject to criminal record review have obtained clearance. Licensing Representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or

Continued on LIC 809-C...

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 SCHOOL
FACILITY NUMBER: 344500637
VISIT DATE: 08/30/2024
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exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated. All fingerprints are on file with the school district.

Facility Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Title 22 Deficiencies were observed during today’s inspection and will be documented on the following page of this report (LIC 809D).

Exit interview conducted and report was reviewed with Substitute Certificated Teacher, Sherlyn Warner. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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