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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393614184
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:35:03 PM

Document Has Been Signed on 11/02/2023 03:35 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:FILLMORE ELEMENTARYFACILITY NUMBER:
393614184
ADMINISTRATOR:TIARA BLAKEFACILITY TYPE:
850
ADDRESS:2644 E. POPLAR STREETTELEPHONE:
(209) 933-7185
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 20DATE:
11/02/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Tiara BlakeTIME COMPLETED:
03:45 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 November 2nd, 2023, at 12:40 PM, Licensing Program Analyst (LPA), David Nguyen met with Site Supervisor, Tiara Blake for the purpose of an unannounced annual inspection. The purpose of the unannounced annual inspection was explained. LPA was granted for entrance by Site Supervisor. Facility days and hours of operation are Monday through Friday from 8:00 AM to 11:00 AM for AM session and from 12:00 PM - 3:45 PM for PM session. There were twenty (20) children present in the PM class during today's inspection. Meals—breakfast and lunch were provided to children in care. The Fillmore Elementary opens between August and May every year. Filtered water was provided for drinking water. Child Care children brought their water bottles for drinking. LPA verified license annual fees are current.

LPA toured the facility inside and out. LPA observed that hazardous items (disinfectants, cleaning solutions etc.) were inaccessible to children in care. LPA reviewed staffing ratios, first aid supplies, furniture, equipment, fire drills and drinking water. The Site Supervisor stated that childcare teachers used water pitcher with filter and children’s cups for drinking water during indoor and outdoor playtimes. LPA observed all required forms to be posted. LPA observed functioning carbon monoxide and smoke alarms. There are adequate toys and equipment available for children. Outdoor play area was toured, the play structure appeared to be in good repair, and there is sufficient cushioning (cushioned turf) under the play structure. LPA reviewed the sign in/out book and observed that the children are properly signed in.

LPA reviewed children’s and staff files. All staff present during today's inspection have a fingerprint clearance. The site supervisor was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Report continues on 809-C...(Page 2)

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
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)
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: FILLMORE ELEMENTARY
FACILITY NUMBER: 393614184
VISIT DATE: 11/02/2023
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 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 observed AB1207 Mandated Reporter training certificates for all staff. The Site Supervisor was reminded to renew the course every 2 years through www.mandatedreporterca.com website.

This provider is currently providing Incidental Medical Services (IMS) services to children in care. IMS policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. LPA observed one (1) medication and one (1) care plan in the classroom. The medication was kept in the plastic box and placed on top of the cabinet above the class’s sink. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm



LPA discussed the Year-Round/Daily Reminder of Water Safety Requirements and Measures with licensee. LPA provided licensee the PIN 23-17-CCLD, the Year-Round and Daily Reminder of Water Safety Requirements and Measures.

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.

Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.

Report continues on LIC809-C...(Page 3)
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: David Nguyen
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
LIC809 (FAS) - (06/04)
Page: 2 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: FILLMORE ELEMENTARY
FACILITY NUMBER: 393614184
VISIT DATE: 11/02/2023
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)

Exit interview conducted and report was reviewed with Site Supervisor, Tiara Blake. A notice of site visit was provided and must remain posted for 30 days. Site Supervisor's signature on this form acknowledges receipt of this form. 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: 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
LIC809 (FAS) - (06/04)
Page: 3 of 3