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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053604815
Report Date: 10/23/2024
Date Signed: 10/23/2024 02:02:43 PM

Document Has Been Signed on 10/23/2024 02:02 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:HAZEL FISCHER EXTENDED DAY PROGRAMFACILITY NUMBER:
053604815
ADMINISTRATOR/
DIRECTOR:		KRISTIAN LERETTEFACILITY TYPE:
840
ADDRESS:1605 BLAGEN ROADTELEPHONE:
(209) 736-6054
CITY:WHITE PINESSTATE: CAZIP CODE:
95223
CAPACITY: 36TOTAL ENROLLED CHILDREN: 18CENSUS: 0DATE:
10/23/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Site Supervisor, Carrie GrahamTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On October 23, 2024, Licensing Program Analyst (LPA) Tobias Lake met with Site Supervisor, Carrie Graham for the purpose of an unannounced annual inspection. Facility does not begin services until 2pm today. Facility days and hours of operation are Monday-Friday from 2:00 PM to 6:00 PM, but on minimum days where kids are let out of school early, hours would be 12:00PM to 6:00PM. There were no children present at the start of today's inspection. LPA reviewed the sign in/out application used and observed that the children are properly signed in.

Licensee was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA toured the facility inside and out. LPA observed that hazardous items were inaccessible to children in care. LPA reviewed first aid supplies, fire drills, and drinking water. LPA observed all required forms to be posted. Site Supervisor stated the fire alarm system includes carbon monoxide as well and is maintained by the school district. LPA observed the toys, furniture and equipment to be in good condition. Outdoor play area was toured. Facility provides snacks to children in care.

LPA reviewed children’s and staff files. LPA observed health screening reports and immunization's for all staff and children. LPA observed at least one staff member present to have current Pediatric CPR and First Aid. LPA observed a valid AB1207 Mandated Reporter training certificate. The site supervisor was reminded to renew the course every 2 years through www.mandatedreporterca.com website.

Report continues on 809-C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Tobias Lake
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HAZEL FISCHER EXTENDED DAY PROGRAM
FACILITY NUMBER: 053604815
VISIT DATE: 10/23/2024
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/
LPA did not observe lead testing clearance on file.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Exit interview conducted and report was reviewed with Site Supervisor, Carrie Graham. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements may result in an immediate civil penalty of $100.

A Type B citation was issued for not having done the required lead testing, see LIC809D.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Tobias Lake
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2024 02:02 PM - It Cannot Be Edited


Created By: Tobias Lake On 10/23/2024 at 01:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HAZEL FISCHER EXTENDED DAY PROGRAM
FACILITY NUMBER: 053604815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.16(a)(1)
Lead Testing
(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bettina Engelman
LICENSING EVALUATOR NAME:Tobias Lake
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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