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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 390317630
Report Date: 05/29/2025
Date Signed: 05/29/2025 02:27:38 PM

Document Has Been Signed on 05/29/2025 02:27 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:HAZELTON ELEMENTARY SCHOOLFACILITY NUMBER:
390317630
ADMINISTRATOR/
DIRECTOR:		RAY SCHRAMFACILITY TYPE:
850
ADDRESS:535 W. JEFFERSONTELEPHONE:
(209) 933-7210
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 46TOTAL ENROLLED CHILDREN: 46CENSUS: 0DATE:
05/29/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Laed Teacher Carole MarquezTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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On 5/29/25, Licensing Program Analyst Carla Polanco Rivera (LPA), met with Lead Teacher Carole Marquez in classroom G-7. Today's visit was for the purpose of an unannounced annual inspection. During today's inspection there were no children present, Teacher stated that it was promotion day for the children and program day was over. Facility days and hours of operation are Monday- Friday, 8:00 AM-2:00 PM.

LPA reviewed care and supervision of children, staffing ratios and first aid supplies, furniture, equipment, fire drills and drinking water. There are adequate toys and equipment available for children. Outdoor play are was toured by LPA and was observed to be in safe conditions. LPA observed all required forms posted. Food is provided by the school district. Menus were posted and drinking water is made readily available to children when in care. LPA reviewed the sign in/out clip boards in classrooms and observed that children are properly signed in.

Staff and children's records were reviewed in classrooms. Files reviewed contained an emergency card and consent for medical treatment. At least one staff member present in each of the classrooms has current Pediatric CPR and First Aid certification, Teacher Carole (Exp. 06/2026). All staff are currently employed through the District and have a criminal record clearance, mandated reporter certificates, and documentation of the educational background, training, and/or experience.


Report Continued on LIC809-C.............
Karyn GuerraTELEPHONE: (916) 216-7790
Carla Polanco RiveraTELEPHONE: (916) 212-0752
DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HAZELTON ELEMENTARY SCHOOL
FACILITY NUMBER: 390317630
VISIT DATE: 05/29/2025
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 LPA observed health screening reports with TB test and required MMR and TDAP vaccines for staff. Staff are required to renew Mandated Reporter training every 2 years, training is available through the www.mandatedreporterca.com website.

Meals are provided by the SUSD school district and served to the children in the classroom.

LPA reviewed storage of medication, and child personnel records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers, sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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

An exit interview was conducted and the report was reviewed with Lead Teacher Carole Marquez. A notice of site visit was posted by LPA in both classrooms and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.



In the areas evaluated, no deficiencies were cited.
SUPERVISOR'S NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR NAME: Carla Polanco RiveraTELEPHONE: (916) 212-0752
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC809 (FAS) - (06/04)
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