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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 153808780
Report Date: 08/02/2022
Date Signed: 08/02/2022 01:24:18 PM

Document Has Been Signed on 08/02/2022 01:24 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:CALIFORNIA IVY LEAGUE PREP ACADEMY, PS & ICFACILITY NUMBER:
153808780
ADMINISTRATOR:MILLER, AMYFACILITY TYPE:
850
ADDRESS:2301 ASHE ROADTELEPHONE:
(661) 832-8300
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93309
CAPACITY: 178TOTAL ENROLLED CHILDREN: 178CENSUS: 73DATE:
08/02/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Amy MillerTIME COMPLETED:
01:35 PM
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On 08/02/22, A case management inspection was conducted today by Licensing Program Analyst (LPA) Jose Penate. LPA met with Director, Amy Miller to discuss incident which occurred on 07/25/22. A complete file review was conducted prior to visit. LPA toured facility inside and outside. A census was taken.


On today’s visit LPA interviewed Staff that were present when the incident occurred. A series of questions were asked regarding the incident and they were discussed with Staff. LPA discussed with staff and verified that visual supervision was on all children at all times and incident did not occur due to negligence.

Exit interview conducted with the Director, Amy Miller.

Per California Code of Regulations Title 22, Division 12, no deficiency cited during today's visit.

LIC 9213 NOTICE OF SITE VISIT FORM IS REQUIRED TO BE POSTED FOR 30 DAYS..
SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Jose Penate
LICENSING EVALUATOR SIGNATURE: DATE: 08/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/02/2022
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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