<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393608171
Report Date: 09/26/2024
Date Signed: 10/24/2024 04:20:01 PM

Document Has Been Signed on 10/24/2024 04:20 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:MADISON ELEMENTARY STATE PRESCHOOLFACILITY NUMBER:
393608171
ADMINISTRATOR/
DIRECTOR:		RAE DANIELLE ANDERSONFACILITY TYPE:
850
ADDRESS:2939 MISSION RD.TELEPHONE:
(209) 466-3122
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 19DATE:
09/26/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Laem, SouphoneTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On September 26th, 2024, at 1:30 PM, Licensing Program Analysts (LPAs), David Nguyen and Janie Davis met with facility representative, Souphone Laem for the purpose of an unannounced annual inspection. The purpose of the unannounced annual inspection was explained. LPAs were granted entrance by facility representative, Souphone Laem. Facility days and hours of operation are Monday-Friday from 7:45 AM to 10:45 AM for AM session, and from 11:15 AM - 2:15 PM for PM session. There were nineteen (19) children present during today's inspection. Meals—breakfast and lunch were provided to children in care. The Madison Elementary State Preschool opens between August and May every year. LPA verified license annual fees are current.

LPAs toured the facility inside and out. LPAs observed that hazardous items (disinfectants, cleaning solutions etc.) were inaccessible to children in care. LPAs reviewed staffing ratios, first aid supplies, furniture, equipment, fire drills and drinking water. LPAs observed all required forms to be posted. LPAs observed functioning carbon monoxide and smoke alarms. There are adequate toys and equipment available for children. LPAs reviewed the sign in/out folders and observed that the children are properly signed in.

Outdoor activity space surface is maintained in a safe condition and is free of hazards. A new play equipment was installed in the playground that is used by the State classroom. LPAs inspected playground equipment and safety labels from the manufacturer. Manufacturer sticker states equipment to be used for two-through-twelve-year-old children. Playground equipment on State classroom was observed to be in good repair and areas around high climbing equipment, swings and slides have cushioning material to absorb falls. Facility representative stated that children brought their water bottles from home for drinking water.

Report continues on LIC809-C...(Page 2)
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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
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: MADISON ELEMENTARY STATE PRESCHOOL
FACILITY NUMBER: 393608171
VISIT DATE: 09/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Page 2)
LPA Davis reviewed children’s and staff files. All staff present during today's inspection have a fingerprint clearance. 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 health screening reports with TB test and required MMR and TDAP vaccines. At least one staff member present today has current Pediatric CPR and First Aid. LPA discussed AB1207 Mandated Reporter training with facility representative. The facility representative was reminded to renew the course every 2 years through www.mandatedreporterca.com website and place the certificates of completion in the licensing files for verification purpose.

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/.

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 stressed the importance of checking the premises for bodies of water daily prior to children’s arrival to improve children’s safety with facility representative.

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

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

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 2 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: MADISON ELEMENTARY STATE PRESCHOOL
FACILITY NUMBER: 393608171
VISIT DATE: 09/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Page 3)
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.

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.

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, Souphone Laem. Appeal Rights and Notice of Site Visit were provided. Licensee's signature on this form acknowledges receipt of this form. Notice of Site Visit was posted and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Report continues on LIC809-C...(Page 4)
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/24/2024 04:20 PM - It Cannot Be Edited


Created By: David Nguyen On 09/26/2024 at 02:52 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MADISON ELEMENTARY STATE PRESCHOOL
FACILITY NUMBER: 393608171

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024

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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2024
Plan of Correction
1
2
3
4
Licensee agrees to have teachers obtain the Mandated Reporter Trainings and submit their certificates of completion for the Manaded Reporter Training to LPA by the POC due date (10/28/2024).
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Chayntel Hunter
LICENSING EVALUATOR NAME:David Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


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: MADISON ELEMENTARY STATE PRESCHOOL
FACILITY NUMBER: 393608171
VISIT DATE: 09/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Page 4)
In the areas that were evaluated, LPA Nguyen informed facility representative, Souphone Laem that this report dated September 26th, 2024 documents one (1) Type B citations during today’s inspection.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5