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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573615400
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:53:00 PM

Document Has Been Signed on 04/25/2024 01:53 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/
DIRECTOR:		JACQUELINE TAMFACILITY TYPE:
850
ADDRESS:1200 ANNA STREETTELEPHONE:
(916) 375-7650
CITY:WEST SACRAMENTOSTATE: CAZIP CODE:
95605
CAPACITY: 144TOTAL ENROLLED CHILDREN: 144CENSUS: 91DATE:
04/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Site Coordinator, Jackie TamTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On April 25, 2024, Licensing Program Analyst (LPA) Lauren Scott met with Site Coordinator, Jackie Tam for the purpose of an unannounced Case Management inspection. LPA observed 91 children supervised by 17 staff.

On April 24, 2024, facility contacted CCLD regarding an Unusual Incident Report (UIR) that stated that 16 children in Preschool Room 11 were outside with 2 staff (substitutes) while the lead teacher was on break. Site Director did a walk through of the room and saw one child was inside the classroom alone. Staff outside did not know the child was missing when the Director brought him back outside. LPA conducted interviews with staff regarding the incident as well.

The facility reported the UIR to Community Care Licensing within 24hrs and were reminded to submit a written UIR was submitted within 7 days.

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 4/25/2024 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: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 04/25/2024 01:53 PM - It Cannot Be Edited


Created By: Lauren Scott On 04/25/2024 at 01:10 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: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2024
Section Cited
CCR
101229(a)(1)

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101229 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 is changing break schedules to ensure transition and outside times are staffed properly. Facility will conduct head counts every 15 mins to ensure children are present. Facility will conduct a staff meeting regarding these changes and supervision and submit notes to LPA with signatures.
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Based on interviews, the facility did not comply with the section cited above where one child was found inside the classroom alone, while the others were outside on the playground, which poses an immediate health, safety or personal rights risk to persons in care.
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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: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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