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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293614615
Report Date: 06/23/2021
Date Signed: 06/23/2021 02:44:05 PM

Document Has Been Signed on 06/23/2021 02:44 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:CARE CAMPUS CHILDREN'S CENTERFACILITY NUMBER:
293614615
ADMINISTRATOR:GUSTAVSON, SANDEEFACILITY TYPE:
850
ADDRESS:10746 SIERRA ROSE CT.TELEPHONE:
(530) 268-8252
CITY:GRASS VALLEYSTATE: CAZIP CODE:
95949
CAPACITY: 45TOTAL ENROLLED CHILDREN: 0CENSUS: 39DATE:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Sandee Gustavson - DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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On Wednesday, June 23rd, 2021, at 11:50am, Licensing Program Analyst (LPA) Blake Morillas met with the Director, Sandee Gustavson, for the purpose of an unannounced Annual Required inspection. At 11:50am, 39 preschool age children and 5 staff in separate rooms were observed. This visit was done in tandem with conducting an unannounced Annual Required visit with their School Age Program, Facility Number 293614616.

Operating hours are 6:45am to 5:40pm, Monday through Friday. The facility operates year around.

At 12:09pm, LPA initiated a health and safety inspection of all indoor and outdoor areas accessible to children. LPA observed that hazardous items (disinfectants, cleaning solutions, etc.) were inaccessible to children in care.

LPA inspected the food service area and observed that the food products appeared to be protected against contamination. Menus were posted.

LPA reviewed care and supervision of children, staffing ratios, health related services (including medications and first aid supplies), furniture, equipment, and fire drills logs. LPA observed all required forms to be posted. Sign/in-sign/out sheet were reviewed.

Drinking water is readily accessible to children in care inside and outside of the building. LPA observed sinks and toilets to be operable. There are adequate toys, equipment, and supplies available for the children. The outdoor play area was observed to have adequate cushioning material and play equipment to be in safe condition. Shaded areas are also available for the children in care.

*Continued on LIC 809-C
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Blake Morillas
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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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Document Has Been Signed on 06/23/2021 02:44 PM - It Cannot Be Edited


Created By: Blake Morillas On 06/23/2021 at 01:28 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: CARE CAMPUS CHILDREN'S CENTER
FACILITY NUMBER: 293614615

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2021
Section Cited
CCR
101170(e)(1)

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101170 Criminal Record Clearance: (e) All individuals subject to a criminal record review. . . shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. . . . This requirement was not
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*Civil Penalty Assessed*
The Director sent both Staff 1 and Staff 2 immediately to be LiveScaned. Director was reminded and confirmed that both Staff 1 and Staff 2 shall not return until their Criminal Record Clearances are fully processed and associated to their License(s).
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met as evidenced by the LPA observing the presence of Staff 1 and Staff 2 who were not listed on the Employee Roster. The Regional Office was called to see if the two staff were fingerprint cleared, but LPA was informed they were not in the system. This is an immediate health and safety 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:Keven Peters
LICENSING EVALUATOR NAME:Blake Morillas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2021


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: CARE CAMPUS CHILDREN'S CENTER
FACILITY NUMBER: 293614615
VISIT DATE: 06/23/2021
NARRATIVE
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*Continuation of LIC 809

At 12:36pm, LPA began to review children’s and staff's files. All staff currently employed with the facility have health screening reports with TB test, immunizations, and Mandated Reporter training. At least one staff member present today has current Pediatric CPR and First Aid.

LPA provided the Lead Testing brochures (AB 2370) and discussed the current Covid-19 protocols and guidelines.

LPA provided the Licensing Agency website (ccld.ca.gov), so the Director may obtain updated licensing information, regulations, and forms.



Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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 for TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the Americans with Disabilities Act, available at: http://www.ada.gov/childqanda.htm

Deficiencies are cited on the subsequent page of this report (LIS 809-D) under the California Code of Regulations, Title 22 of the California Health and Safety Code.

The Director was provided a copy of the Appeal Rights (LIC9058).

At 2:30pm, LPA reviewed the report with the Director and an exit interview was conducted.

LPA provided a Notice of Site Visit and the Director acknowledges that this notice shall remain posted for 30 days for parental review.



The Director's signature on this form acknowledges receipt of this report and said documents.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Blake Morillas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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