394500843-6-13-2023-53-CC-ASIS-CSRNHZ-20230613102936

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 394500843
Report Date: 06/13/2023
Date Signed: 06/13/2023 11:27:32 AM

Document Has Been Signed on 06/13/2023 11:27 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:	CAPC - SHASTA		FACILITY NUMBER:	394500843
ADMINISTRATOR:	KIM BALLARD		FACILITY TYPE:	850
ADDRESS:	751 EAST EDISON STREET		TELEPHONE:	(209) 464-4524
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY: 24	TOTAL ENROLLED CHILDREN: 24	CENSUS: 0	DATE:	06/13/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kim Ballard		TIME COMPLETED:	11:00 AM

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	Application Specialist (AS) Alecia Sifuentes met with Early Education Director, Kim Ballard for the purpose of an announced pre-licensing inspection. Applicant requests a preschool license to serve 24 preschool children from age two to entry into kindergarten. The program will operate Monday through Friday from 7:45 a.m. to 3:15 p.m. and is located at Shasta Elementary School. The fire clearance was granted and received on 6/12/2023. The facility will provide morning and afternoon snacks. AS reviewed with Early Education Director the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted. INDOOR ACTIVITY SPACE: There is one preschool classroom. AS observed a sufficient amount of equipment, toys, tables, chairs, and cubbies. There is a first aid kit in the classroom. Medications will be stored in the medication backpack that is hung up and out of reach of children. AS observed cleaning disinfectants are appropriately stored and inaccessible to children. Early Education Director stated there are no poisons or firearms on the premises. AS observed water dispenser in the classroom. AS observed a functional dual smoke and carbon monoxide detector in the classroom. AS observed an electronic sign-in/sign-out system. AS measured the classroom. The total classroom space contains a total of 997 square feet, which will accommodate Applicant's request for 24 preschool children. There is one toilet and two sinks located in the classroom for the children, and a separate private restroom for the staff. Early Education Director has requested a Shared Bathroom Waiver. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the quite area of the classroom and will use the staff restroom, if necessary. Report continues on LIC809-C.

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CAPC - SHASTA	FACILITY NUMBER: 394500843
	VISIT DATE: 06/13/2023

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

OUTDOOR ACTIVITY SPACE:
There is one outdoor area on the property. The outdoor play area is fenced with a chain link fence that is at least four feet tall. Early Education Director has requested a Shared Outdoor Space Waiver. There is a play structure that includes a safety label, which designates use for children 5 years old and above. Early Education Director understand that children who are under the age of 5 years old cannot utilize the play structure. There are no bodies of water on the premises. There are shaded areas supplied by trees and overhangs.

AS measured the outdoor activity space. The outdoor play area contains a total of 18,538 square feet, which will accommodate Applicant's request for 24 preschool children. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. 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: 100% supervision is required at all times, including in the bathroom; personal rights; inspection authority; reporting requirements; staff to children ratios and capacity; staff qualifications; and maintaining buildings and grounds. AS discussed with Early Education Director 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.

Early Education Director was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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 LIC809-C.

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CAPC - SHASTA	FACILITY NUMBER: 394500843
	VISIT DATE: 06/13/2023

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

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with Early Education Director, Kim Ballard.

The following items are required before a license will be issued:
1. Final file review from Licensing Program Manager (LPM)

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3