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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573615400
Report Date: 01/29/2024
Date Signed: 01/29/2024 01:08:19 PM

Document Has Been Signed on 01/29/2024 01:08 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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:YCOE ALYCE NORMAN HSFACILITY NUMBER:
573615400
ADMINISTRATOR:JACQUELINE TAMFACILITY TYPE:
850
ADDRESS:1200 ANNA STREETTELEPHONE:
(916) 375-7650
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95605
CAPACITY: 144TOTAL ENROLLED CHILDREN: 144CENSUS: 115DATE:
01/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Site Director, Jackie TamTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lauren Scott and Licensing Program Manager (LPM) met with Site Coordinator, Jackie Tam for the purpose of an unannounced Case Management inspection.

On January 23, 2024, facility contacted CCLD regarding an Unusual Incident Report (UIR) that stated one child climbed the play yard fence and left the school premises. LPA conducted interviews with staff and learned the child ran to a playground located off site, behind the school campus. Although staff immediately followed the child, there was a brief period staff lost visual supervision of the child.

Based on the interviews and information obtained, one Title 22 Deficiency has been issued on the attached LIC 809-D. The facility was informed that this report dated 1/29/2024 documents one Type A citation which shall be posted for 30 consecutive days. The facility shall also provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Facility has been provided with appeal rights.

Exit interview conducted and report was reviewed with Site Coordinator, Jackie Tam. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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 01/29/2024 01:08 PM - It Cannot Be Edited


Created By: Lauren Scott On 01/29/2024 at 12:22 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: YCOE ALYCE NORMAN HS
FACILITY NUMBER: 573615400

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision... (1) No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation. This requirement was not met as evidenced by:
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Facility will submit a zoning map as well as a safety plan to prevent any future occurrences. Facility will discuss these at a staff meeting and submit signed meeting notes to LPA.
Facility has already assessed the yard and moved any furniture making climbing accessible.
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Based on interviews, a child eloped from the facility and staff briefly lost visual supervision of the child, which poses an immediate health, safety or personal rights risk to persons in care.

THIS IS A REPEAT VIOLATION
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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:Chayntel Hunter
LICENSING EVALUATOR NAME:Lauren Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024


LIC809 (FAS) - (06/04)
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