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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393621662
Report Date: 09/15/2022
Date Signed: 09/15/2022 02:59:24 PM

Document Has Been Signed on 09/15/2022 02:59 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: 21DATE:
09/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Candi KettgenTIME COMPLETED:
03:00 PM
NARRATIVE
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On 09/15/2022, Licensing Program Analysts Katy Maestas (LPA1) and Mariya Melnichuk (LPA2) conducted a field visit to the Center for the purpose of a case management inspection regarding a self reported Unusual Incident Report (UIR). LPAs arrived at the Center and were met by Director Candi Kettgen (D1). LPA1 disclosed the purpose of the inspection and was granted entrance into the Center. LPAs toured the Center and observed 21 preschool aged children being supervised by 5 adults. School aged children arrived during LPAs visit. LPA1 determined through accessing Guardian that all required adults are background cleared.

LPA1 requested a copy of the Facility Roster and documents pertaining to the UIR. LPAs photographed documents and the grounds. LPA1 interviewed D1 and 3 staff members. Based on LPAs observations and interviews, a Civil Penalty will be assessed on a subsequent 809-D page in the amount of $250.00. This violation was cited within the last 12 months which constitutes a repeat violation. The previous violation occurred on 05/18/2022 for allowing a child to be left without supervision of a teacher and lacking visual observation. This Civil penalty will continue to accrue $100 per day until the deficiency is
cleared.

An exit interview was conducted and the report was reviewed with D1. Licensee Appeal Rights were provided to D1. 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.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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 09/15/2022 02:59 PM - It Cannot Be Edited


Created By: Nola Maestas On 09/15/2022 at 02:05 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: TINY TOTS ACADEMY
FACILITY NUMBER: 393621662

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/16/2022
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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D1 reported that a Staff Meeting immediately occurred to discuss transition policies, a baby-gate was installed intot he hallway of the facility and signs were posted to keep gates and doors closed.
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This requirement was not met as evidenced by: A self reported UIR that documented that a child followed an adult out of the facilty without a staff member's supervision on 08/26/2022. This is a repeat violation, as the first violation occurred on 05/18/2022.
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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:Jeanne Smith
LICENSING EVALUATOR NAME:Nola Maestas
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2022


LIC809 (FAS) - (06/04)
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