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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343608219
Report Date: 12/08/2023
Date Signed: 12/08/2023 02:36:38 PM

Document Has Been Signed on 12/08/2023 02:36 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MERRYHILL SCHOOL - HARBOUR POINTFACILITY NUMBER:
343608219
ADMINISTRATOR:STEPHANIE GILLFACILITY TYPE:
850
ADDRESS:9561 HARBOUR POINT DRIVETELEPHONE:
(916) 683-3244
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 120TOTAL ENROLLED CHILDREN: 120CENSUS: 92DATE:
12/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Stephanie GillTIME COMPLETED:
04:00 PM
NARRATIVE
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On 12/08/2023, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit to the facility for the purpose of a case management inspection regarding a self reported Unusual Incident Report (UIR) dated 12/04/2023. LPA arrived at the facility and was met by Director Stephanie Gill (D1). LPA disclosed the purpose of the inspection and was granted entrance into the facility. 92 preschool aged children were present during today's inspection. LPA determined, through accessing Guardian, that all required adults were background cleared and associated to the license.

LPA conducted staff interviews. Interviews corroborate what was reported in the UIR: 2 children were left without supervision on the playground on 12/01/2023. This posed an immediate risk to the health and safety of children in care. As a result of the absence of supervision, a Type-A deficiency was cited on a subsequent 809-D page and a Civil Penalty was assessed. D1 understands that all parents or authorized representatives of currently enrolled children must sign the LIC 9224 form and be available to the Department for review. D1 understands that parents or authorized representatives of children enrolling for up to one year must sign the LIC 9224 form and be available to the Department for review. D1 acknowledged that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809-D with Type A deficiencies for 30 days.

An exit interview was conducted, and the report was reviewed with D1. LPA provided D1 with Licensee Appeal Rights. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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 2
Document Has Been Signed on 12/08/2023 02:36 PM - It Cannot Be Edited


Created By: Katy Velazquez On 12/08/2023 at 02:08 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MERRYHILL SCHOOL - HARBOUR POINT
FACILITY NUMBER: 343608219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2023
Section Cited
CCR
101229

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time, ...
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D1 will conduct a transition observation of all staff members on 12/08/2023. D1 will email LPA a signed form of the observation by 5 PM on 12/11/2023.
D1 plans on conducting a staff meeting on 12/29/2023 which will include training on supervision.
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Supervision shall include visual observation.

This requirement was not met as evidenced by 2 children being left unsupervised on the playground on 12/01/2023.
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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:Karyn Guerra
LICENSING EVALUATOR NAME:Katy Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023


LIC809 (FAS) - (06/04)
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