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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393610882
Report Date: 12/05/2023
Date Signed: 12/06/2023 11:15:45 AM

Document Has Been Signed on 12/06/2023 11:15 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:VICTORY STATE PRESCHOOLFACILITY NUMBER:
393610882
ADMINISTRATOR:CLAUDIA LIBORIOFACILITY TYPE:
850
ADDRESS:1838 W. ROSE STREETTELEPHONE:
(209) 933-7380
CITY:STOCKTONSTATE: CAZIP CODE:
95203
CAPACITY: 44TOTAL ENROLLED CHILDREN: 44CENSUS: 15DATE:
12/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Susie StevensTIME COMPLETED:
01:30 PM
NARRATIVE
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On December 5th, 2023, at 10:30 AM, Licensing Program Analyst (LPA), David Nguyen conducted an unannounced field visit to the facility. LPA was granted for entry into the facility by Facility Representative, Patricia Sanchez Medina. LPA Nguyen met with Senior Program Specialist, JoAnn Eggert to follow up on the Unusual Incident Report (UIR) submitted to Community Care Licensing, Division (CCLD) on November 17th, 2023.

LPA toured the facility, observed the care and supervision of children, reviewed records and conducted onsite interviews with teachers. During today’s field visit, LPA toured the facility and observed fifteen (15) children being supervised by five (5) adult teachers.

LPA determined through record review and teachers’ onsite interviews that one of the childcare teachers miscounted the childcare children during transition, and one of the childcare teachers found one (1) childcare child unattended in the classroom for approximately 2 minutes while the class was outside with the teachers, which poses an immediate health, safety, or personal rights risk to persons in care.

A Type A violation was assessed on a subsequent 809-D page. Senior Program Specialist shall post LIC 809-D with Type A deficiency 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. LIC9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the Licensees.

LIC9224 and Appeal Rights were provided. An exit interview was conducted, and the report was reviewed with Senior Program Specialist. Licensee Appeal Rights were provided to Senior Program Specialist. A Notice of Site visit was posted by LPA 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 2)

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2023
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 12/06/2023 11:15 AM - It Cannot Be Edited


Created By: David Nguyen On 12/05/2023 at 12:28 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: VICTORY STATE PRESCHOOL
FACILITY NUMBER: 393610882

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2023
Section Cited
CCR
101229(a)(1)

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(a) The licensee shall provide care and supervision as necessary to meet the children's needs.
(1) No child(ren) shall be left without the supervision of a teacher at any time, … Supervision shall include visual observation.

This requirement was not met as evidenced by:
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Staff Meeting was held to focus on Supervision. The Compliance Specialist emailed LPA the sign-in sheet from this meeting. The Compliance Specialist created a written statement for staff to sign that describes supervision policy and procedures will be expected of staff for the future.
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Based on record review and onsite teachers’ interviews, one childcare child was left unattended in the classroom during transition for approximately 2 minutes, which poses an immediate risk to children in care.
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Compliance Specialist of Stockton Unified School District emailed the signed statements to LPA.

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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:Chayntel Hunter
LICENSING EVALUATOR NAME:David Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023


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: VICTORY STATE PRESCHOOL
FACILITY NUMBER: 393610882
VISIT DATE: 12/05/2023
NARRATIVE
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(Page 2)

Senior Program Specialist acknowledges, that for TYPE A DEFICIENCIES ONLY upon receipt, Director shall post LIC 809-D.

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

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
LIC809 (FAS) - (06/04)
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