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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317664
Report Date: 11/02/2023
Date Signed: 11/02/2023 12:11:09 PM

Document Has Been Signed on 11/02/2023 12:11 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:PULLIAM SCHOOLFACILITY NUMBER:
390317664
ADMINISTRATOR:KRYSTAL TAYLORFACILITY TYPE:
850
ADDRESS:230 PRESIDIO WAYTELEPHONE:
(209) 951-2459
CITY:STOCKTONSTATE: CAZIP CODE:
95207
CAPACITY: 22TOTAL ENROLLED CHILDREN: 18CENSUS: 13DATE:
11/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cynthia HammondTIME COMPLETED:
12:30 PM
NARRATIVE
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On 11/02/23, Licensing Program Analyst (LPA), Elvira Sierra conducted an unannounced Cse Management inspection and met with Facility representative, Cynthia Hammond and ECE Program Specialist, Carmelita Roman. Present were four staff supervising 13 children. Program is in compliance with Staff/Child ratios on today's inspection.

During the inspection, facility representatives and LPA discussed unusual incident occurred on 10/30/23 in which Child #1 remain alone in the classroom while the rest of the children/staff were in the school cafeteria. Staff stated that they noticed Child #1 was missing from the rest of the group within seconds and staff went back to the classroom where Child # 1 was alone playing on the ground with some toys. ECE Specialist stated that a Staff meeting will be held on 11/2/23 to train staff on active supervision. Child #1 continues to attend the program. LPA observed adequate levels of supervision on today's inspection.

See attached 809D for deficiency cited. Exit interview conducted and this report and Appeal of Rights were reviewed and provided to facility representatives, Cynthia Hammond and Carmelita Roman. Notice of Site Visit posted and should remain posted for 30 days. FOR TYPE A DEFICIENCIES ONLY, upon receipt, facility representative shall post this report with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. The LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt. (LIC 9224 was provided).

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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Document Has Been Signed on 11/02/2023 12:11 PM - It Cannot Be Edited


Created By: Elvira Sierra On 11/02/2023 at 11:30 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: PULLIAM SCHOOL
FACILITY NUMBER: 390317664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2023
Section Cited
CCR
101229(a)(1)

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101229 (a)(1) Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision.....(1) No child(ren) shall be left without the supervision of a teacher at any time..... This requirement was not met as evidence by;
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ECE Specialist stated stated that program will held a staff meeting regarding active supervision. Facility will provided LPA with an agenda of the training attendance held on 11/2/23 for a plan of correction.
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Facility self reported that a child was left behind in the classroom during transition to the school cafeteria. This is a violation that if not corrected poses an immediate risk to the children 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:Bettina Engelman
LICENSING EVALUATOR NAME:Elvira Sierra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
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