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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343614395
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:45:18 PM


Document Has Been Signed on 06/22/2023 04:45 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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:MISSION AVENUE PRESCHOOLFACILITY NUMBER:
343614395
ADMINISTRATOR:CHRISTINA DIAZ BUSHMANFACILITY TYPE:
830
ADDRESS:2433 MISSION AVENUETELEPHONE:
(916) 487-4647
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:22CENSUS: 4DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Christina Diaz BushmanTIME COMPLETED:
04:50 PM
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On June 22, 2023 at approximately 12:15 PM, Licensing Program Analyst (LPA) Josiah Gathing and Licensing Program Manager Seychelle De Luca met with Director Christina Diaz Bushman for the purpose of an unannounced annual random inspection. During today’s inspection there were nine infants being supervised by four staff. The facility days and hours of operation are Monday through Friday from 6:00 AM to 6:00 PM.

LPA toured the indoor classroom areas, children’s restrooms, staff restroom, kitchen, and outdoor play areas. Director stated there are no poisons or firearms on the premises. Toxic and hazardous items are inaccessible to children. Furniture and equipment are in good condition. Playground equipment and surfaces are free of loose or sharp parts. Restrooms are in sanitary condition with functioning toilets. The floors were clean throughout the facility.

LPA observed that solid waste containers were covered. LPA observed log book containing infant feeding plans. Infant changing tables were within arm’s reach of sink areas per regulation. LPA observed a manual sign in and out sheet with parent’s full signatures. LPA observed required posted documents near the facility entrance.

All present staff files were reviewed and found to be complete. At least one present staff had a current CPR/First Aid certificate which will expire August 24, 2023.

LPA observed the sample of children’s files contained the appropriate documents. LPA observed a fire drill log last dated May 26, 2023. LPA observed complete children’s roster on file. The facility is equipped with First Aid equipment and fire extinguishers meeting licensing requirements.

Report continues on LIC809-C.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Josiah GathingTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2023
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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MISSION AVENUE PRESCHOOL
FACILITY NUMBER: 343614395
VISIT DATE: 06/22/2023
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LPA discussed the safe sleep regulations with Facility Representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (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

Director was encouraged to the visit the Department's website at WWW.CCLD.CA.GOV for information regarding child care updates, PINs, forms, regulations and legislation pertaining to child care centers.
No deficiencies were cited based on today’s inspection.

Exit interview was conducted and report was reviewed with the Director. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Josiah GathingTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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