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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407468
Report Date: 12/16/2021
Date Signed: 12/20/2021 02:26:42 PM

Document Has Been Signed on 12/20/2021 02:26 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:ST. JOHN THE BAPTIST CATHOLIC PRESCHOOLFACILITY NUMBER:
073407468
ADMINISTRATOR:WILSON, RACHELFACILITY TYPE:
850
ADDRESS:11156 SAN PABLO AVE.TELEPHONE:
(510) 234-2244
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 41TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
12/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rachel WilsonTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced Annual Required inspection. There were 3 staff and 10 children present during the inspection. Furniture and equipment was observed to be in good condition, free of sharp, loose, or pointed parts. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children were inaccessible during the visit. The toilets and sinks were in operable condition. The floors were free of tripping hazards. The kitchen/food preparation and storage areas were observed to be clean. Food is protected against contamination. All storage containers for solid waste have tight-fitting covers that are in good repair. Menus are posted and visible for parents to review. Climbing equipment is properly anchored to the ground with adequate and appropriate cushioning material to absorb falls.

The facility is operating within its licensed capacity. The facility is within ratio today with one teacher supervising no more than 12 children. LPA did not observe any child left without visual supervision or unattended during the inspection. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility.

Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record 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.

A sample of children and staff records were reviewed.
Fire/Disaster drill are conducted at least once every six months.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ST. JOHN THE BAPTIST CATHOLIC PRESCHOOL
FACILITY NUMBER: 073407468
VISIT DATE: 12/16/2021
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Incidental Medical Services (IMS) policy was discussed. 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

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process



During file review the following deficiencies were observed:

-Children's files did not have Consent for Medical Treatment on file.
-Children's files did not have signed admission agreement on file.

Notice of Site Visit was provided and must be posted for 30 days.
Exit interview was conducted with Rachel Wilson
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Cherie Acosta
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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Document Has Been Signed on 12/20/2021 02:26 PM - It Cannot Be Edited


Created By: Cherie Acosta On 12/16/2021 at 04:35 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ST. JOHN THE BAPTIST CATHOLIC PRESCHOOL

FACILITY NUMBER: 073407468

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 12/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101221(b)(6)
Child's Records
(b) Each record shall contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 101219.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2022
Plan of Correction
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Director shall ensure all files have a signed admission agreement. Director shall submit a letter to CCL by 1/14/22 ensuring this is done.
Type B
Section Cited
CCR
101221(b)(8)(C)
Child's Records
(C) A signed consent form for emergency medical treatment unless the child's authorized
representative has signed the statement specified in Section 101220(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 5 out of 5 files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/14/2022
Plan of Correction
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Director shall ensure all files have a signed consent for medical treatment. Director shall submit a letter to CCL by 1/14/22 ensuring this is done.
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:Cherie Acosta
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021


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