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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243808137
Report Date: 08/18/2021
Date Signed: 08/18/2021 12:21:20 PM

Document Has Been Signed on 08/18/2021 12:21 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:DOS PALOS STATE PRESCHOOLFACILITY NUMBER:
243808137
ADMINISTRATOR:BIRDSALL, JOANNEFACILITY TYPE:
850
ADDRESS:1734 CALIFORNIA AVETELEPHONE:
(209) 392-0267
CITY:DOS PALOSSTATE: CAZIP CODE:
93620
CAPACITY: 67TOTAL ENROLLED CHILDREN: 0CENSUS: 34DATE:
08/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Virgina FrancoTIME COMPLETED:
12:30 PM
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On 08/18/2021 Licensing Program Analyst (LPA) Robert Gutierrez, conducted an unannounced Annual Required Inspection for the preschool license. LPA met with Site Supervisor, Virgina Franco and toured the facility indoors and outdoors. Days and hours of operation are Monday – Friday 8:00 AM – 11:00 AM and 12:00 PM – 3:00 PM. This facility operates mid-August through May.

There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible. No poisons were observed during the inspection.

Furniture and equipment are in good condition, free of sharp, loose or pointed parts. Playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All toilets and handwashing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors. Areas around high climbing equipment and slides have cushioning material to absorb falls. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements. Staff fingerprint through Dos Palos Unified School District as a condition of employment. Capacity and limitations as specified on the license are being maintained. LPA was provided expired CPR cards and was informed that an in person training was conducted on July 30th and that staff are still waiting on certificates. The name of the child care center director or fully-qualified teacher(s) designated to act in the director’s absence has been reported to the Department. The person who signs the child in/out of the facility shall use their full legal signature and record the time of day. All children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than 12 children in care.

Continued on 809-C

SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Robert Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/18/2021
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: DOS PALOS STATE PRESCHOOL
FACILITY NUMBER: 243808137
VISIT DATE: 08/18/2021
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LPA reviewed a sample of children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child and medical assessment. LPA reviewed a sample of staff files and observed files were complete with immunization records for influenza, pertussis and measles. Staff #1 (S1) and Staff #2 (S2) did not have a current Mandated Reporter Training certificate on file. Menus are posted at least one week in advance where an authorized representative can view them.

Incidental Medical Services (IMS) are currently being provided. Licensee is aware that an IMS plan needs to be submitted. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.



LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiency are being cited: (see next page, 809 D) Licensee was provided a copy of their appeal rights.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISORS NAME: Susie Fanning
LICENSING EVALUATOR NAME: Robert Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/18/2021 12:21 PM - It Cannot Be Edited


Created By: Robert Gutierrez On 08/18/2021 at 11:45 AM
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: DOS PALOS STATE PRESCHOOL
FACILITY NUMBER: 243808137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2021
Section Cited
HSC
1596.8662(3)

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Current proof of completion for each licensed child care provider or applicant for that license, administrator, and employee of a licensed child day care facility shall be submitted to the department upon inspection of the child day care or upon request by the department. This requirement is not met as evidenced by file review conducted during today’s inspection.
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Licensee stated S1 and S2 shall take this training and send a certificate to the Community Care Licensing (CCL) office located in Fresno. This correction shall be submitted by the given due date.
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Upon inspection, licensee was unable to provide LPA with S1 and S2 current mandated reporter training. This poses as a potential risk to the health, safety, or personal rights of 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:Susie Fanning
LICENSING EVALUATOR NAME:Robert Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2021


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