293623806-6-25-2021-03-CC-BMOS-C4BPVV-20210625113947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 293623806
Report Date: 06/25/2021
Date Signed: 06/25/2021 11:39:55 AM

Document Has Been Signed on 06/25/2021 11:39 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:	MT. ST. MARY ACADEMY		FACILITY NUMBER:	293623806
ADMINISTRATOR:	WENDY BEESLEY		FACILITY TYPE:	850
ADDRESS:	400 S. CHURCH STREET		TELEPHONE:	(530) 273-4694
CITY:	GRASS VALLEY	STATE: CA	ZIP CODE:	95945
CAPACITY: 22	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	06/25/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Edee Wood - Admin. Macy Wood - Teacher		TIME COMPLETED:	12:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On Friday, June 25th, 2021, at 9:05am, Licensing Program Analyst (LPA) Blake Morillas and Licensing Program Manager (LPM) Keven Peters conducted a site inspection for the purpose of a Prelicensing visit. LPA and LPM met with Edee Wood, the Administrator, and Macy Wood, a Teacher of the facility. The facility is requesting a Preschool License for 22 Preschool age children. The facility's anticipated opening date is August 18th, 2021. Hours will be 8:00am to 3:00pm, Monday through Friday. At this time it is unknown if they will follow the school calendar or be open year around. At 9:06am, LPA initiated a health and safety inspection of all areas accessible to children. INDOOR ACTIVITY SPACE: The Preschool program will be located in the basement of the Mt. St. Mary Elementary School building. The space consists of a classroom, a common area, and 2 bathrooms for children usage, with one stall being designated for ill child use. These bathrooms will be shared with the TK program and a Bathroom Waiver will be issued. The staff bathroom is located on the 3rd floor. There are a total of 10 toilets, 3 urinals, and 6 sinks for children use. The classroom and common area are equipped with child size furnishings. There are individual cubbies for storing children's personal belongings. Due to Covid restrictions on the Elementary School food program, at this time the Preschool will require parents to supply their children with snacks and lunch. Once restrictions are lifted, hot meals provided by the Elementary School will be offered for a fee to the preschool program. Medications will be kept labeled, locked, and stored in the "Sick Room." Sign in/out will be done electronically. *Continued on LIC 809-C (Page 1 of 3)

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Blake Morillas
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

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 3

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: MT. ST. MARY ACADEMY	FACILITY NUMBER: 293623806
	VISIT DATE: 06/25/2021

NARRATIVE

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*Continuation of LIC 809 (Page 2 of 3)

Facility will also use water cups and bottles for water due to Covid restrictions on drinking fountains. Facility has first aid kits. All hazardous materials such as cleaning solutions are inaccessible to children. There are no bodies of water at the facility. The fire clearance has been received and approved. The classroom contains a total approximate measurement of 782 square feet, which is enough to accommodate the requested capacity of 22 Preschool age children. The common area measurement is approximately 622 square feet.

OUTDOOR ACTIVITY SPACE:
The outdoor play area consist of a independently fenced playground and a side yard which is part of the main playground, with the side yard being used on occasion. In the side yard, there is a permanently installed and fixed fire escape ladder by the entrance to the Preschool program. At the time of the inspection the ladder was roughly made inaccessible. A discussion was had and it was noted that the base of the ladder would be surrounded with temporary fencing to make in inaccessible to the Preschool children. There is sufficient resilient material on the ground. There is a shaded area available outside. The outdoor activity spaces were measured. Measurements for the independently fenced playground was was 2,484 square feet, which does accommodate the approved capacity of 22 Preschool Age children. The side yard measured 2,268 square feet. Due to Covid restrictions on the usage of drinking fountains, the facility will utilize water bottles and cups for children when outside.

This facility plans to provide Incidental Medical Services (IMS). A 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 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, are available at: http://www.ada.gov/childqanda.htm.

*Continued on LIC 809-C

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Blake Morillas
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: MT. ST. MARY ACADEMY	FACILITY NUMBER: 293623806
	VISIT DATE: 06/25/2021

NARRATIVE

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*Continuation of LIC 809-C (Page 3 of 3)

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

Effective today (6-25-2021) the facility is PROVISIONALLY LICENSED (Expires 9-25-2021) to serve a Capacity of up to 22 Preschool Children ages 2.5 to 4 years old.

Final approval and removal of Provisional status will be granted once all pre-discussed documents are submitted, reviewed, and approved by Licensing.

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

At 11:25am, LPA reviewed the report with the Teacher (LIC 308 for the Teacher was received) and an exit interview was conducted.

Notice of site visit posted.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Blake Morillas
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3