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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093623234
Report Date: 09/29/2021
Date Signed: 11/17/2021 12:47:10 PM

Document Has Been Signed on 11/17/2021 12:47 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:PINE TOP INFANT & TODDLER CTR (PS)FACILITY NUMBER:
093623234
ADMINISTRATOR:BROWN, KARENFACILITY TYPE:
850
ADDRESS:5723 PONY EXPRESS COURTTELEPHONE:
(530) 391-2604
CITY:POLLOCK PINESSTATE: CAZIP CODE:
95726
CAPACITY: 12TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
09/29/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jill KimeTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Michelle Pascual met with Director Jill Kime for the purpose of an announced case management visit. The Director requests to increase the capacity from 12 to 14 preschool children. The program will operate in the large preschool classroom identified as Preschool room C which is already licensed. LPA received fire clearance on 09/17/2021.

A health and safety inspection was conducted in all areas accessible to children. LPA measured 1 classroom, The total indoor capacity for the preschool classroom (room C) is 515.023 square feet. This will accommodate the additional 2 additional children requested. LPA observed sufficient amount of furniture, toys, and play equipment in the classrooms. LPA observed a functional carbon monoxide detector in each classroom. LPA observed disinfectants and medications are inaccessible and stored appropriately. There are 3 toilets and 3 sinks in the co-ed bathroom and a separate staff restroom is available. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the front office area.
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: PINE TOP INFANT & TODDLER CTR (PS)
FACILITY NUMBER: 093623234
VISIT DATE: 09/29/2021
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There is 1 outdoor area on the property that has been previously licensed. The outdoor play area is enclosed with a fence that is at least four feet tall. LPA observed a sufficient amount of equipment and toys. There are no bodies of water on the premises. There are shaded areas supplied by overhangs. LPA observed an outdoor play structure with a safety label for ages 2 years to 5 years.

The total outdoor capacity is 21,375 square feet for the original outdoor play structure area which is adequate for two additional children . Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

Director was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request.

An exit interview was conducted and in the areas that were evaluated, no deficiencies were observed at the time of the inspection This facility evaluation report was reviewed and discussed with Director. LPA emailed a copy of the 809 to Director. Director understands she must read the reports and send back an acknowledgement that she read and received the report. LPA also emailed LIC311A, Effects of Lead Exposure brochure, and immunization card.
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Michelle Pascual
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021
LIC809 (FAS) - (06/04)
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