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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 103808837
Report Date: 07/13/2023
Date Signed: 07/13/2023 04:05:28 PM

Document Has Been Signed on 07/13/2023 04:05 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:JEFFERSON STATE PRESCHOOLFACILITY NUMBER:
103808837
ADMINISTRATOR:TUPPER, MEGANFACILITY TYPE:
850
ADDRESS:1296 E. WASHINGTONTELEPHONE:
(559) 305-7237
CITY:REEDLEYSTATE: CAZIP CODE:
93654
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 16DATE:
07/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Lead Teacher Carla DouhanTIME COMPLETED:
04:00 PM
NARRATIVE
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On 07/13/2023 Licensing Program Analyst (LPA) Jose Penate, conducted an unannounced case management deficiency inspection. LPA met with Lead Teacher, Carla Douhan. The purpose of today’s inspection was to follow up on an incident that occurred at the facility on 07/11/2023 in which child #1 was left unsupervised in the outdoor play area for approximately eight to ten minutes. Early Learning Coordinator, Megan Tupper, reported to the incident to Community Care Licensing Division (CCLD) on 07/11/2023.

During today’s inspection LPA interviewed staff #1 whom was associated with the incident. Information obtained revealed that staff #1 , staff #2, and staff #3 were present during outdoor play time at approximately 09:45am on 07/11/2023. As the children were transitioning from outdoor to indoor. Prior to children returning to classroom staff #1 gave head count to other staff members, at the time she counted 6 children. Staff #2 confirmed count and proceeded to enter classroom without any knowledge of any other children being left in the outdoor play area. Staff and children then entered classroom and approx.. 8 to 10 minutes upon entering classroom staff #1 verified the count of children and noticed child #1 was not in the classroom. Staff immediately checked the outdoor playground area and observed child #1 in the outdoor play area hiding in the play structure tunnel, he was brought back into the classroom and observed for any injuries. Child #1 was deemed safe by staff and then immediately contact child #1’s guardians and Megan Tupper.

LPA observed the outdoor playground area and observed the play area that is utilized by preschoolers to be safe and open for visual supervision. The gate to the playground is self-latching and has an additional locking mechanism so that only staff members can open the gate. LPA discussed with lead teacher to utilize an easel board outdoors and write down the count of children in attendance when at outdoor play so that all staff members are aware of the count of children returning to classroom. LPA also recommended to have staff members assigned areas of responsibility (Staff Zone) to ensure all children are supervised while at outdoor play and to also ensure visual supervision at all times.

Continued on LIC809-C

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: JEFFERSON STATE PRESCHOOL
FACILITY NUMBER: 103808837
VISIT DATE: 07/13/2023
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Based on the above information obtained through interviewing staff #1 and through details obtained during the self-reporting process, and per California Code of Regulations Title 22 Division 12 Chapter 1, the following deficiency is being cited. (See 809-D). Appeal rights were provided.

Upon receipt of this report, facility shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A completed signed copy of the LIC 9224 will need to be completed by each parent for each child in care.

Notice of Site Inspection to be posted for 30 days from today’s inspection.

Exit interview conducted with Lead Teacher, Carla Douhan.

SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2023 04:05 PM - It Cannot Be Edited


Created By: Jose Penate On 07/13/2023 at 02:28 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: JEFFERSON STATE PRESCHOOL
FACILITY NUMBER: 103808837

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2023
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision.
(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1)No child(ren) shall be left without the supervision of a teacher at any
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Facility will create a plan to ensure supervision of children at all times and also create a plan for staff members to conduct a thourough inspection prior to transitioning from outdoor to indoors.
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time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. Based on information that was self reported and interviews conducted. This poses an immediate health, safety, and/or personal rights risk to children in care.
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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:Duane Matsubara
LICENSING EVALUATOR NAME:Jose Penate
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023


LIC809 (FAS) - (06/04)
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