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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343600373
Report Date: 05/07/2024
Date Signed: 05/07/2024 04:18:02 PM


Document Has Been Signed on 05/07/2024 04:18 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:MERRYHILL SCHOOL - LAGUNA PARKFACILITY NUMBER:
343600373
ADMINISTRATOR:MCKENZIE DAVISFACILITY TYPE:
830
ADDRESS:6613 LAGUNA PARK DRIVETELEPHONE:
(916) 684-4044
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:24CENSUS: 14DATE:
05/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:McKenzie DavisTIME COMPLETED:
04:45 PM
NARRATIVE
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On 05/07/2024, Licensing Program Analyst Katy Velazquez (LPA1) and Licensing Program Analyst Elizabeth Santiago (LPA2) conducted a field visit to the facility for the purpose of a Case Management inspection. LPAs arrived at the center and were met by Director McKenzie Davies (D1). LPA1 disclosed the purpose of the inspection and was granted entrance into the facility. LPAs conducted a tour of the facility and observed 14 infants being supervised by 5 staff member. LPA1 determined, through accessing Guardian, that 1 individual, who was observed to be providing care and supervision to children, was not associated to the license.
This poses an immediate risk to the health and safety of children in-care. As a result, a Type-A deficiency was cited on a subsequent 809-D page and a Civil Penalty was assessed. D1 understands that all parents or authorized representatives of currently enrolled children must sign the LIC 9224 form and be available to the Department for review. D1 understands that parents or authorized representatives of children enrolling for up to one year must sign the LIC 9224 form and be available to the Department for review. D1 acknowledged that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809-D with Type A deficiencies for 30 days.
An exit interview was conducted, and the report was reviewed with Director Davies. LPA provided Licensee Appeal Rights to D1. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Katy VelazquezTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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 2


Document Has Been Signed on 05/07/2024 04:18 PM - It Cannot Be Edited

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: MERRYHILL SCHOOL - LAGUNA PARK
FACILITY NUMBER: 343600373

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2024
Section Cited
CCR
101216(i)(2)

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(i) Prior to employment or initial presence in the child care center, all employees and volunteers subject to a criminal record review shall:... (2) Request a transfer of a criminal record clearance as specified in Section 101170(f)...
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LPA will immediatley access Guardian and associate Laura Petersen to the license. D1 will call Officer of the Day and inquire about fingerprints and associations PRIOR to any individual being on location that will provide care and supervision to children in care.
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This requirement was not met as evidenced by LPA1 observing Laura Petersen providing care and supervision ot infants on 05/07/2024.
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LPA was able to associate Petersen and provide D1 with a letter of clerance while on location.

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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: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Katy VelazquezTELEPHONE: 916-926-9100
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
LIC809 (FAS) - (06/04)
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