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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 500316980
Report Date: 05/15/2024
Date Signed: 05/15/2024 12:44:49 PM

Document Has Been Signed on 05/15/2024 12:44 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
FRESNO CC RO, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:TUOLUMNE HEAD STARTFACILITY NUMBER:
500316980
ADMINISTRATOR/
DIRECTOR:		NUNES, HEIDIFACILITY TYPE:
850
ADDRESS:707 HERNDON RDTELEPHONE:
(209) 574-8442
CITY:MODESTOSTATE: CAZIP CODE:
95351
CAPACITY: 45TOTAL ENROLLED CHILDREN: 20CENSUS: 17DATE:
05/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:34 AM
MET WITH:Kimbra DraperTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 05/15/2024, Licensing Program Analyst (LPA) Miguel Herrera conducted an unannounced case management inspection at the facility. LPA met with Kimbra Draper, who accompanied LPA during a tour of the facility both inside and outside. LPA explained the purpose for the inspection and a census was taken. During the case management visit, facility observations were completed, facility records were reviewed, and an interview was conducted with staff#1.

Based on interview and records review, LPA Herrera confirmed, that while playing in the facility’s playground child #1 sustained an injury that required medical treatment. The child tripped and fell after her shoe slipped out her foot while she was running in the playground. Staff immediately treated the injury and called the child’s parent. The incident occurred at approximately 11:10am on 04/02/2024 and the facility self reported the incident on 05/06/2024. Based on observation and records review LPA Herrera confirmed that the facility failed to report the incident to the Fresno Regional Office either by telephone or fax within 24 hours of the occurrence.



Per California Code of Regulations, Title 22, Division 12, Chapter 1, this deficiency is being cited on the attached LIC 809D. An exit interview was conducted with ECE Coordinator, Kimbra Draper. A copy of this report and Appeal Rights were provided and discussed with ECE Coordinator, Kimbra Draper. A Notice of Site Visit Form was posted to parent's board and must remain posted for 30 days.
SUPERVISORS NAME: Juvenal Moctezuma
LICENSING EVALUATOR NAME: Miguel Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2024
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 05/15/2024 12:44 PM - It Cannot Be Edited


Created By: Miguel Herrera On 05/15/2024 at 12:20 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: TUOLUMNE HEAD START
FACILITY NUMBER: 500316980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2024
Section Cited
CCR
101212(d)(1)(B)

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101212(d)(1)(B) Reporting Requirements(d)Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event......
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On May 9, 2024, ECE Coordinator, Kimbra Draper reviewed and trained staff regarding Reporting Requirements (CCR, section 101212). On May 9, 2024, ECE Coordinator Draper submitted the UIR along with an attendance list of all staff that attended the training. Therefore the plan of correction was already completed.
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This requirement was not met as evidenced by: Based on that the facility did not report incident to CCL as stated in LIC809 within 24 hours of the occurrence. This poses a potential risk to the health, safety, or personal rights of children.
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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:Juvenal Moctezuma
LICENSING EVALUATOR NAME:Miguel Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024


LIC809 (FAS) - (06/04)
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