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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406688
Report Date: 10/03/2022
Date Signed: 10/03/2022 12:53:32 PM

Document Has Been Signed on 10/03/2022 12:53 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:PITTSBURG USD - LOS MEDANOS STATE PRESHOOLFACILITY NUMBER:
073406688
ADMINISTRATOR:TUTT, PHYLLISFACILITY TYPE:
850
ADDRESS:610 CROWLEY AVETELEPHONE:
(925) 473-2300
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 24TOTAL ENROLLED CHILDREN: 26CENSUS: 15DATE:
10/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Laura SerratosTIME COMPLETED:
12:55 PM
NARRATIVE
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On 10/3/22 at 11:40 AM Licensing Program Analyst (LPA) Michelle Sutton conducted an unannounced Annual Inspection at Los Medanos State Preschool. During today's inspection it was determined that Los Medanos Preschool has relocated into a new building on Los Medanos Elementary school campus for the new school year on 8/10/22. Facility previously was located in Portable A on the elementary school campus.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the lead teacher Laura Serratos.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Michelle Sutton
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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Document Has Been Signed on 10/03/2022 12:53 PM - It Cannot Be Edited


Created By: Michelle Sutton On 10/03/2022 at 11:55 AM
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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: PITTSBURG USD - LOS MEDANOS STATE PRESHOOL
FACILITY NUMBER: 073406688

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2022
Section Cited
CCR
101237(a)

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101237 Alterations to Existing Buildings or New Facilities (a) Prior to construction or alterations, the licensee shall notify the Department of the proposed change(s). This requirement is not met as evidenced by:
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By POC date 10/24/22 Licensee shall submit LIC200A and a Facility sketch to LPA.
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Based on observation, record review and interview, the licensee did not comply with the section cited above by not informing CCLD of the new building and location of the preschool, which poses a potential health, safety or personal rights risk to persons in care.
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Additional information may be requested by the app unit.

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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Michelle Sutton
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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