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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500637
Report Date: 08/22/2025
Date Signed: 08/28/2025 11:00:05 AM

Document Has Been Signed on 08/28/2025 11:00 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/
DIRECTOR:		SANDRA WIESTFACILITY TYPE:
850
ADDRESS:10070 LOUSADA DRIVETELEPHONE:
(916) 831-2098
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 24TOTAL ENROLLED CHILDREN: 23CENSUS: 20DATE:
08/22/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Deborah MillanTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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**This is an amended report.**

On August 22,2025, Licensing Program Analyst (LPA) Corina Beckby met with Substitute Teacher, Deborah Millan, for an unannounced required annual random inspection. LPA observed 3 substitutes supervising 20 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 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 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.

The AM Head Start program is served breakfast and lunch and the PM State program is served lunch. All meals are provided by the school district. LPA observed posted menus showing planned meals at least one week in advance. Non-contaminated 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...

NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Corina Beckby
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2025
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 5
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 08/28/2025 11:00 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/27/2025 07:32 AM


Created By: Corina Beckby On 08/22/2025 at 02:57 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MIWOK VILLAGE ELEMENTARY SCHOOL
FACILITY NUMBER: 344500637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
101216.1(b)
Teacher Qualifications and Duties
(b) Prior to employment, a teacher shall meet the requirements of (b)(1) or (b)(2) below:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and unable to review recods, the licensee did not comply with the section cited above in 3 out of 3 out of teachers present, did not have personnel files to review, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Licensee will have qualifed ECE staff present at all times. If qualified subs are not available, the Program manager and other district staff will step in until ECE qualified staff are available.
Type A
Section Cited
CCR
101223(a)(3)
Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in thta LPA Beckby observed children throwing wooden blocks, magnet tiles, and legos at each other. A substitute member turned away after seeing one incident. A substitute stood and did not engage when children were fighting over toys on the carpet or when the tiles were being thrown. LPA observed a substitute bend over at the child's level, raise her voice saying "NO" while pointing her finger at him. LPA heard a substitute tell a child to "Put your stinky shoes on."; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/26/2025
Plan of Correction
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Qualified teachers will supervise children and work on preventing injures by maintaining a safe and healthy environment and ratio. ****THIS IS AN AMENDED REPORT.****
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bettina Engelman
NAME OF LICENSING PROGRAM MANAGER:
Corina Beckby
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
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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: 08/22/2025
NARRATIVE
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LPA observed full legal signatures while reviewing the sign in and sign out sheet. 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.

Criminal record clearances are on file with the district. 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 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.

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.

LPA Beckby informed facility representative, Deborah Millen, that this report dated 08/22/2025 documents Type A citations. Type A citations shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA Beckby informed the facility representative to provide a copy of this licensing report dated 08/22/2025 to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Continued on LIC 809-C...

NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Corina Beckby
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 08/22/2025
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If these requirements are not met, civil penalties will be assessed.

An Exit interview was conducted, and the report was reviewed with facility representative, Deborah Millen. LPA posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of three years for public review upon request. The Licensee's signature on this form acknowledges receipt of this form.

NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Corina Beckby
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC809 (FAS) - (06/04)
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