394500974-12-11-2023-53-CC-ASIS-CYEPJ2-20231211102049

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 394500974
Report Date: 12/11/2023
Date Signed: 12/11/2023 12:37:50 PM

Document Has Been Signed on 12/11/2023 12:37 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:	KOALA TREE MONTESSORI		FACILITY NUMBER:	394500974
ADMINISTRATOR:	MILLER, PATRICIA		FACILITY TYPE:	850
ADDRESS:	2057 E. MAIN ST		TELEPHONE:	(415) 685-1665
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95205
CAPACITY: 22	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	12/11/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Paola Jack		TIME COMPLETED:	10:30 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	Centralized Application Bureau (CAB) Licensing Program Analyst (LPA Alecia Sifuentes and Licensing Program Analyst (LPA) David Nguyen met with Applicant, Paola Jack for the purpose of a prelicensing inspection. Applicant requests a preschool license to serve 22 preschool children from age two to entry into transitional kindergarten. The program will operate Monday through Friday from 7:30 a.m. to 6:00 p.m. The fire clearance was granted and received on 12/5/2023. The facility will provide breakfast, lunch, and afternoon snacks. LPA reviewed with Applicant 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 are two preschool classrooms. LPA observed a sufficient amount of equipment, toys, tables, chairs, cubbies, and napping cots. There is a first aid kit in each of the classrooms and one in the hallway. Medications will be stored in the large preschool classroom cabinet. LPA observed cleaning disinfectants are appropriately stored and inaccessible to children. Applicant stated there are no poisons or firearms on the premises. Applicant will order a water dispenser for the classrooms. LPA did not observed a functional carbon monoxide detector. Applicant will purchase a detector and provide LPA with a photo. Applicant will have parents use sign in/sign out binders. LPA measured two classrooms. The total classroom space contains a total of 971.89 square feet, which will accommodate Applicant's request for 22 preschool children. There are 3 toilets and 3 sinks for the children located in the Women's restroom, and a separate private restroom for the staff located in the Men's restroom. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the office and will use the staff restroom, if necessary. Report continues on LIC809-C.

SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KOALA TREE MONTESSORI	FACILITY NUMBER: 394500974
	VISIT DATE: 12/11/2023

NARRATIVE

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OUTDOOR ACTIVITY SPACE:
There is one outdoor area on the property. The outdoor play area is fenced with a wrought iron fence and chain link/wooden fence that is at least four feet tall. LPA observed a sufficient amount of equipment and toys. The play structure does not include a safety label. LPA requested documentation indicating the age range the play structure is approved for. Applicant provided LPA will the manufacturers product information which indicated the use for children 2 to 12 years old. There are no bodies of water on the premises. There are shaded areas supplied by overhangs and one canopy.

LPA measured the outdoor activity space. The outdoor play area contains a total of 4,652 square feet, which will accommodate Applicant's request for 22 preschool children. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated 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) or (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 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. LPA 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.

Applicant 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, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center.

Report continues on LIC809-C.

SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KOALA TREE MONTESSORI	FACILITY NUMBER: 394500974
	VISIT DATE: 12/11/2023

NARRATIVE

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A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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 the Applicant, Paola Jack.

The following items are required before a license will be issued:

1. Photo of carbon monoxide detector
2. Final file review and approval from Licensing Program Manager (LPM) Mai Lor.

SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

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