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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 290300690
Report Date: 09/16/2022
Date Signed: 09/16/2022 11:11:29 AM

Document Has Been Signed on 09/16/2022 11:11 AM - 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:TALL PINES NURSERY SCHOOL INCFACILITY NUMBER:
290300690
ADMINISTRATOR:ANDERSON, KELSEYFACILITY TYPE:
850
ADDRESS:11228 MCCOURTNEY ROADTELEPHONE:
(530) 273-4638
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95945
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 19DATE:
09/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Sarah UllomTIME COMPLETED:
11:30 AM
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An unannounced annual/random inspection is made today by Licensing Program Analyst Amanda Blesi. LPA Blesi met with business manager, Sarah Ullom. The director Kelsey Anderson and one teacher were observed supervising 19 preschool age children. The facility runs a parent co-op so parent volunteers were also present today.

The following areas are in compliance during inspection: There are no bodies of water. Firearms and ammunition are not on the premises. No poisons are kept on site. Disinfectants, hazardous items and medications are inaccessible to children. Furniture and equipment are sufficient, age appropriate and in good repair. Fire drills are conducted according to Title -22 Regulations. Playground was free of loose or sharp parts. Bathroom was clean and toilets and sinks were in working condition. Classrooms are safe and clean. Carbon Monoxide detector is on the premises. Storage containers for solid waste are covered. The facility provides snack and lunch. Drinking water is available both indoors and outside. Menus are posted. The facility is in compliance with conditions and limitations specified on the license. Teacher/child ratios are maintained and adequate supervision is being provided during this inspection. There is adequate space for children belongings. Napping equipment are in good repair. Sign in/sign out sheets maintained. All waivers are being followed.

Facility representative was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

First Aid/CPR reviewed and in compliance. Emergency information reviewed for some children. Staff records reviewed contain documentation of the educational background, training, and/or experience.


Continued on next page…LIC809-C

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
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: TALL PINES NURSERY SCHOOL INC
FACILITY NUMBER: 290300690
VISIT DATE: 09/16/2022
NARRATIVE
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LPA observed proof that all staff/ volunteers have met the requirements of SB 792.

LPA observed that all staff has completed the required mandated reporter training (AB 1207) at website: www.mandatedreporterca.com

LPA discussed Assembly Bill 2370, which will require licensed Child Care facilities to test their water for excessive amounts of lead. Testing will be required beginning January 1st, 2020 to January 1st, 2023 and must be conducted every five years from initial testing.

LPA provided the Community Care Licensing website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current in regards to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws childcareadvocatesprogram@dss.ca.gov.



This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Report is continued on the following page LIC 809-C
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/16/2022 11:11 AM - It Cannot Be Edited


Created By: Amanda Blesi On 09/16/2022 at 10:54 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: TALL PINES NURSERY SCHOOL INC
FACILITY NUMBER: 290300690

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101170(d)
Criminal Record Clearance
(d) All individuals subject to criminal record review shall, be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury.

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 employee Sarah Ullom did not have a fingerprint clearance on file with the Department which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2022
Plan of Correction
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Sarah States she got a Livescan last year however there was no record of a fingerprint clearance in Guardian, nor LIS according to front office staff Khatera. The employee did not have a staff file on site (she stated it was at home) therefore it could not be verified if she had a copy of her DOJ clearance letter. To correct the deficiency, the facility shall submit proof that Sarah Ullom has a criminal record clearance with our Department. This shall be corrected wihtin 24 hours and proof of correction shall be sent to LPA Blesi @ Amanda.Blesi@dss.ca.gov.
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:Keven Peters
LICENSING EVALUATOR NAME:Amanda Blesi
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022


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: TALL PINES NURSERY SCHOOL INC
FACILITY NUMBER: 290300690
VISIT DATE: 09/16/2022
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LPA Blesi informed facility representative Sarah Ullom that this report dated 9.16.22 document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Blesi informed the facility representative to provide a copy of this licensing report dated 9.16.22 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the facility representative Sarah Ullom.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC809 (FAS) - (06/04)
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