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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621662
Report Date: 05/18/2022
Date Signed: 05/18/2022 12:57:04 PM

Document Has Been Signed on 05/18/2022 12:57 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:TINY TOTS ACADEMYFACILITY NUMBER:
393621662
ADMINISTRATOR:KETTGEN, CANDIFACILITY TYPE:
850
ADDRESS:250 NORTHGATE DRIVETELEPHONE:
(209) 294-9803
CITY:MANTECASTATE: CAZIP CODE:
95336
CAPACITY: 43TOTAL ENROLLED CHILDREN: 43CENSUS: 35DATE:
05/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Candi kettgenTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christopher Jackson met with licensee Candi Kettgen to follow up on the Unusual Incident Report (UIR) called into Community Care Licensing on May 11, 2022. During today's inspection LPA conducted a tour of the facility.

The center self reported that on 5/10/22, during the evening transition time a student walked out of the facility. The child left the facility without staff’s knowledge. LPA conducted interviews and obtained information pertinent to the incident. It was revealed that Child #1, followed another family out of the building and was then brought back into the center by the same parent. LPA conducted interviews with the licensee and Staff present during the incident.

A Type A deficiency was cited on the subsequent page (809-D) of this report.

Facility evaluation report was reviewed and discussed with licensee. Exit interview was conducted. A Notice of Site Visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Christopher Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2022
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 2
Document Has Been Signed on 05/18/2022 12:57 PM - It Cannot Be Edited


Created By: Christopher Jackson On 05/18/2022 at 11:58 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: TINY TOTS ACADEMY
FACILITY NUMBER: 393621662

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/19/2022
Section Cited
CCR
101220(a)(1)

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No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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The licensee said, the staff will ensure the child is within line of site of the staff during the transition process. The facility will conduct a Staff Meeting with topics to include visual supervision and copies of Meeting Agenda and Sign-In Sheets will be submitted to the Department. In addition licensee said staff
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This requirement was not met as evidenced by: Facility self reported that Child#1 followed a family out of the facility without staff supervision on 5/10/22
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will conduct head counts from one room. Then recount the children upon arrival in the next room to ensure all children are present. The center will also require the classroom door to remain closed during pick up and parents will be allowed access by a staff member opening the door upon arrival for pick up.

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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:Justin L Denton
LICENSING EVALUATOR NAME:Christopher Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022


LIC809 (FAS) - (06/04)
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