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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500460
Report Date: 12/08/2021
Date Signed: 12/08/2021 02:23:00 PM

Document Has Been Signed on 12/08/2021 02:23 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:ASPIRE BEN HOLT MIDDLE SCHOOLFACILITY NUMBER:
394500460
ADMINISTRATOR:AUTUMN WRIGHTFACILITY TYPE:
840
ADDRESS:3201 EAST MORADA LANETELEPHONE:
(209) 955-1477
CITY:STOCKTONSTATE: CAZIP CODE:
95212
CAPACITY: 90TOTAL ENROLLED CHILDREN: 18CENSUS: 11DATE:
12/08/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Autumn WrightTIME COMPLETED:
03:00 PM
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Application Specialist (AS) Alecia Sifuentes met with Licensee Representative/Director, Autumn Wright for the purpose of an announced pre-licensing inspection. Licensee requests a school-age license to serve 90 school-age children from and above. The program will operate Monday through Friday from 6:00 a.m. to 6:00 p.m. AS observed on file Ben Holt Middle School’s annual fire inspection which was approved on 3/4/2021.

Licensee acknowledges that the following documents must be posted at all times: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, car seat poster, menus, and daily schedule. AS discussed the forms that must be in each child's and each staff member's file. AS provided LIC311A and Effects of Lead Exposure brochure. The school provides snack for the facility.

INDOOR ACTIVITY SPACE:
There is one school-age classroom located in portable 202. The school-age children also occupies the gym. AS observed a sufficient amount of equipment, tables and chairs. Medication is stored in a lockbox inside the classroom cabinet and refrigerated medication is stored in the office. The first aid kit is stored in the classroom cabinet. AS observed cleaning disinfectants are appropriately stored and inaccessible to children. Applicant stated there are no poisons or firearms on the premises. Children use water bottles filled from the cafeteria. AS observed a functional dual smoke and carbon monoxide detector in the classroom. AS observed a sign-in/sign-out binder. Licensee stated that they will being using an electronic sign-in/sign-out system soon.

Report continues on 809-C.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: ASPIRE BEN HOLT MIDDLE SCHOOL
FACILITY NUMBER: 394500460
VISIT DATE: 12/08/2021
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OUTDOOR ACTIVITY SPACE:
There is one outdoor area on the property as well as the school court yard. The outdoor play area is fenced with a chain link and wrought iron fence that is at least four feet tall. AS observed a sufficient amount of equipment and toys. There are no bodies of water on the premises. There are shaded areas supplied by overhangs.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A Plan of Operation that includes IMS must be submitted to the Department. 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

AS discussed the following: supervision; personal rights; inspection authority; reporting requirements; staff to children ratios and capacity; staff qualifications; and maintaining buildings and grounds. AS discussed with Applicant any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

This facility evaluation report was reviewed and discussed with Applicant. Applicant was encouraged to the visit the Department's website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to child care centers.

AS will issue a provisional license that will expire in 90 days on 3/8/2022. Once the provisional is issued, the following items are to be submitted prior to expiration of the provisional license for final approval of license:

1. Remaining documents listed on LIC184.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC809 (FAS) - (06/04)
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