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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093616215
Report Date: 03/29/2022
Date Signed: 03/29/2022 01:46:19 PM

Document Has Been Signed on 03/29/2022 01:46 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:COUNTRY KIDS DAYCARE & PRESCHOOLFACILITY NUMBER:
093616215
ADMINISTRATOR:SPRINGER, ASHLEEFACILITY TYPE:
850
ADDRESS:610 PLEASANT VALLEY ROADTELEPHONE:
(530) 642-1630
CITY:DIAMOND SPRINGSSTATE: CAZIP CODE:
95619
CAPACITY: 28TOTAL ENROLLED CHILDREN: 28CENSUS: 15DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Ashlee SpringerTIME COMPLETED:
02:00 PM
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On 3/29/22 at 10:25AM a required annual inspection was made to the facility by Licensing Program Analyst (LPA), Martinez and Manabat and met with Director Ashlee Springer. The facility file was reviewed prior to this inspection. A review of the personnel report on 3/28/22 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The facility’s operating hours are 7-6, Mon-Fri. The facility was toured at 10:50AM time inside and outside and the floor and yard plan submitted by the licensee were verified.
The licensee stated no firearms or weapons are stored on site and none were observed. There are no pools or similar bodies of water. Poisons are locked under the sink. Furniture and equipment are in good condition and free of hazards. The outdoor activity space was cushioned with bark and free of hazards. Toilets and sinks are operating properly. The kitchen/food preparation area is clean, and free of litter or rodents. Food is properly stored and free of contamination. Trash cans have tight fitting lids. Drinking water is available to children both inside by drinking fountain and water bottles. The facility was free of flies, insects and rodents. The facility has a working carbon monoxide detector.

(Cont)
SUPERVISORS NAME: Maria Mayorga
LICENSING EVALUATOR NAME: Mikah Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: COUNTRY KIDS DAYCARE & PRESCHOOL
FACILITY NUMBER: 093616215
VISIT DATE: 03/29/2022
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During today's inspection, staffing ratios were being met and there were 15 children were being supervised by 2 teachers/aides. Children are not left without visual supervision at any time. The facility was operating within the licensed capacity. At least one staff member present during the visit (S1) possessed current CPR and First Aid certifications. The sign in/out sheet was reviewed, and representatives are using full signatures and recording the time. Staff are provided on-the-job training, including sanitation and universal precautions. Children with symptoms of illness are not accepted, and children who become ill during the day they are sent home. A weekly menu was posted near the entry of the building.

Nine children’s records were reviewed at 12PM, and contained emergency identification forms and medical assessments. One childs file was missing updated immunization cards. Two staff records were reviewed at 12:30PM, and contained health screening forms, proof of mandated reporter training, and proof of immunization's.

All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.
SUPERVISORS NAME: Maria Mayorga
LICENSING EVALUATOR NAME: Mikah Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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Document Has Been Signed on 03/29/2022 01:46 PM - It Cannot Be Edited


Created By: Mikah Martinez On 03/29/2022 at 12:33 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: COUNTRY KIDS DAYCARE & PRESCHOOL
FACILITY NUMBER: 093616215

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101220.1(g)
Immunizations
(g) The licensee shall document each child's immunizations and shall maintain such documentation in the center for as long as the child is enrolled.

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 1 out of 9 Children files, which is a immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2022
Plan of Correction
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Licensee agrees to submit updated immunization to CCLD no later than 4/1/22.
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:Maria Mayorga
LICENSING EVALUATOR NAME:Mikah Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022


LIC809 (FAS) - (06/04)
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