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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 033605372
Report Date: 05/23/2023
Date Signed: 05/23/2023 10:02:13 AM

Document Has Been Signed on 05/23/2023 10:02 AM - 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:PLYMOUTH STATE PRESCHOOLFACILITY NUMBER:
033605372
ADMINISTRATOR:HOLLINGSWORTH, TAMARANFACILITY TYPE:
850
ADDRESS:18601 SHERWOOD STREETTELEPHONE:
(209) 283-0844
CITY:PLYMOUTHSTATE: CAZIP CODE:
95669
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: 19DATE:
05/23/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michelle PechetteTIME COMPLETED:
10:30 AM
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Application Specialist (AS) Alecia Sifuentes and Licensing Program Analyst (LPA) Mariya Melnichuk met with Licensee Representative Michelle Pechette and Site Supervisor Tamaran Hollingsworth for the purpose of a case management inspection. Licensee requests a room change to room 16 and a change of capacity to serve 24 preschool children age two years to entry into kindergarten. The preschool program is located at Plymouth Elementary School. The fire clearance was granted and received on 5/10/2023, The program currently operates Monday through Friday from 8:15 a.m. to 11:15 a.m.

INDOOR ACTIVITY SPACE:
There is one preschool classroom located in room 16. AS observed a sufficient amount of equipment, toys, tables, chairs, and cubbies. AS measured room 16. The total classroom space contains a total of 1,576 square feet, which will accommodate Licensee’s request for 24 preschool children. There are two toilets and three sinks for the children, and a separate private restroom for the staff. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

OUTDOOR ACTIVITY SPACE:
There is one outdoor area on the property. AS used current outdoor measurements. The outdoor area contains a total of 4,431 square feet, which will accommodate Licensee’s request for 24 preschool children.

Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Report continues on LIC809-C.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2023
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 SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: PLYMOUTH STATE PRESCHOOL
FACILITY NUMBER: 033605372
VISIT DATE: 05/23/2023
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A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Licensee Representative, Michelle Pechette.

Effective today, 5/23/2023, AS will approve the room change and change of capacity for 24 preschool children.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Alecia Sifuentes
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
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