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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390319950
Report Date: 01/23/2025
Date Signed: 01/23/2025 05:48:26 PM

Document Has Been Signed on 01/23/2025 05:48 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:MONTEZUMA SCHOOLFACILITY NUMBER:
390319950
ADMINISTRATOR/
DIRECTOR:		FLORES, GABRIELAFACILITY TYPE:
850
ADDRESS:2843 FARMINGTONTELEPHONE:
(209) 933-7255
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 48TOTAL ENROLLED CHILDREN: 33CENSUS: 30DATE:
01/23/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Boun, Phouthone TiaTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On January 23rd, 2025, at 12:15 PM, Licensing Program Analyst (LPA), David Nguyen met with facility representative, Phouthone Tia Boun to conduct an unannounced annual inspection. The purpose of the unannounced annual inspection was explained. LPA was granted entrance into childcare facility by facility representative.

The Head Start program in the portable is Monday through Friday, from 8:00 am to 2:00 pm and serves breakfast and lunch to children. The AM State Preschool program located in room 4 is Monday through Friday, from 7:45 am to 10:45 am, and serves breakfast to children. The PM State Preschool program located in room 4 is Monday through Friday, from 11:15 am to 2:15 pm, and serves lunch to children. All meals—breakfast and lunch—are provided by the Stockton Unified School District. There were thirteen (13) children present in the Head Start class and fifteen (15) children present in the State Preschool Class at the time of inspection. LPA verified the annual license fees are up to date.

LPA toured the inside and outside of the facility, including all activity/classroom areas, restrooms, and outdoor play areas. Outdoor play area was toured, the play structure appeared to be in good repair, and there is sufficient cushioning (wood chips) under the play structure.

LPA observed two toilets and two sinks for use by the children in the Head Start portable. LPA observed a separate staff bathroom which was inaccessible to the children. Cleaning supplies were stored in an upper locked cabinet. LPA observed children's toys were in good condition and in sufficient supply. LPA reviewed staffing ratios, first aid supplies, furniture, equipment, fire drills and drinking water. LPA observed functioning carbon monoxide and smoke alarms. LPA observed that all the required forms were posted including a license, meal/snack menu that meets regulation, parents' rights' poster, emergency care and disaster plan and seat belt laws.

Report continues on LIC809-C...(Page 2)
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2025
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 3
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: MONTEZUMA SCHOOL
FACILITY NUMBER: 390319950
VISIT DATE: 01/23/2025
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(Page 2)
LPA reviewed health related services, including first aid supplies, furniture, equipment, drinking water and food service provisions. LPA reviewed the sign/in-sign/out sheet, children's records, and personnel records. All staff present during today's inspection have a fingerprint clearance through the Stockton Unified School District. Facility 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.

LPA observed that health screening reports and proof of immunization are centrally stored in an off-site location. At least one staff member present during today's inspection has current Pediatric CPR and First Aid. LPA observed training certificate for approved third party mandated reporter training resource for all staff. LPA observed AB1207 Mandated Reporter training certificates for all staff. Facility representative was reminded to renew the course every 2 years through www.mandatedreporterca.com website.

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 verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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/.

Report continues on LIC809-C...(Page 3)

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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: MONTEZUMA SCHOOL
FACILITY NUMBER: 390319950
VISIT DATE: 01/23/2025
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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 discussed the Year-Round/Daily Reminder of Water Safety Requirements and Measures with facility representative. LPA provided facility representative the PIN 23-17-CCLD, the Year-Round and Daily Reminder of Water Safety Requirements and Measures. LPA discussed the importance of checking for bodies of water on the school’s premises daily prior to children’s arrival for children's safety with facility representative.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.



Facility representative was encouraged to visit the Department website at WWW.CCLD.CA.GOV for childcare updates, current forms, legislation, and regulation information.

Exit interview conducted and report was reviewed with facility representative, Phouthone Tia Boun. Appeal rights and a notice of site visit were provided. A copy of this report will remain on file for a period of three years for public review upon request. Facility representative’s signature on this form acknowledges receipt of this form. A notice of site visit was posted and must remain posted for 30 days for parental review. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during the inspection.

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC809 (FAS) - (06/04)
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