Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503600291
Report Date: 04/19/2016
Date Signed: 04/19/2016 01:33:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 E.SHAW AV,STE 300-MS 29-01
FRESNO, CA 93710
FACILITY NAME:EMPIRE HEAD STARTFACILITY NUMBER:
503600291
ADMINISTRATOR:CENTENO, CONSUELOFACILITY TYPE:
850
ADDRESS:5201 FIRST STTELEPHONE:
(209) 527-9884
CITY:EMPIRESTATE: CAZIP CODE:
95319
CAPACITY:20CENSUS: 20DATE:
04/19/2016
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Connie CentenoTIME COMPLETED:
01:55 PM
NARRATIVE
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LPA Claudia Henley conducted a case management visit today. LPA at facility due to an incident which occurred on 4/11/16. I was met by Site Supervisor Connie Centeno. Toured facility and census was taken.

LPA interviewed with staff regarding the incident. On 4/11/16 at approximately 12:00 p.m. Child #1 was signed into the center by the parent representative (grandmother). Child #1 completed the required health check with Staff #1 and the grandmother left the facility and exited through the gate to the parking lot area. Child #1 exited out of the classroom to go find her grandmother. The grandmother advised staff that she observed Child #1 attempting to open facility entrance/exit gate to come out into the parking lot. The grandmother took Child #1 back into the classroom and advised staff that she was outside. Staff were not aware that Child #1 exited out of the classroom. According to the sign in/sign out sheets there were two staff and 15 children signed into the center at the time of incident.

The following is cited per Title 22 Regulations (see page 2). Appeal Rights left with center representative. Site Visit Notice posted on the parent board. Exit interview was conducted with Site Supervisor.

The licensee shall post and provide copies of this licensing report to parents/guardians of children in care and to parents/guardians of children newly enrolled at the facility during the next 12 months. A copy of this report must be given to each enrolled child's parent(s). The licensee was provided a copy of the "Fact Sheet" for AB 633 (Parent Notification Requirements), along with a copy of the relevant documents this date. The licensee must implement the new procedure immediately, by having all parents of enrolled children sign the Acknowledgement of Receipt of Licensing Reports and must retain a copy in each child's file.



SUPERVISOR'S NAME: Valarie ReedTELEPHONE: (559) 243-8093
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 243-4588
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2016
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
CCLD Regional Office, 770 E.SHAW AV,STE 300-MS 29-01
FRESNO, CA 93710
FACILITY NAME: EMPIRE HEAD START
FACILITY NUMBER: 503600291
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2016
Section Cited
101229(a)(1)
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101229(a)(1) Care and Supervision (Zero Tolerance): No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). On 4/11/16 between the hour of 12:00 p.m.-12:10 p.m., a 5 year old child (Child #1) exited out of the classroom to the facility entrance/exit parking lot gate to locate her grandmother
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Site Supervisor provided a copy of staff's "Child Active Supervision Plan" which was revised on 4/18/16. A staff meeting was conducted on 4/14/16 and new strategies/plan was implimented for the safety of children. The front door to the classroom will remain shut during the sign in process. New signs have been posted on the gate to remind parents to latch/lock the entrance/exit gates.
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who had just left the facility. The grandmother observed her grandchild attempting to open the gate to come onto the parking lot area. The grandmother returned her grandchild back to the classroom. Staff present in the classroom were not aware that Child #1 left the facility.
Due to this facility being State funded, the immediate civil penalty for a zero tolerance deficiency is exempt.
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Additional latch/locks were installed on the other remaining gates. Licensee will be installing a door alarm on the classroom exit/entrance door. Send the receipt and photograph showing the installation of the alarm on the door by 4/26/16. This Type A deficiency will be submitted to management for further review. A non-compliance maybe required in the near future and will be notified through the mail.
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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: Valarie ReedTELEPHONE: (559) 243-8093
LICENSING EVALUATOR NAME: Claudia HenleyTELEPHONE: (559) 243-4588
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2016
LIC809 (FAS) - (06/04)
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