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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343616702
Report Date: 04/23/2025
Date Signed: 04/24/2025 03:24:17 PM

Document Has Been Signed on 04/24/2025 03:24 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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CAMELLIA PRESCHOOLFACILITY NUMBER:
343616702
ADMINISTRATOR/
DIRECTOR:		HAMMOND, ALYCEFACILITY TYPE:
850
ADDRESS:6600 COUGAR DRIVETELEPHONE:
(916) 395-4520
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 25TOTAL ENROLLED CHILDREN: 25CENSUS: 20DATE:
04/23/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Reena SharmaTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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On Wednesday April 23rd 2025, Licensing Program Analyst (LPA) Mandie Goodwin met with facility representative Reena Sharma for the purpose of an unannounced random inspection and a case management to follow up on a reported lead exceedance. LPA toured the facility at which time a census of 20 preschool children supervised by three staff members were observed. The facility hours of operation are Monday through Friday from 8:00 AM to 2:30 PM in room 1 on the Camellia Elementary School campus.

A health and safety inspection was conducted in the classroom, restroom, food service area, and outdoor play area. Facility provides breakfast, lunch, and snack. LPA observed all postings. Cleaning disinfectants and hazardous items are appropriately stored and inaccessible to children. Furniture and equipment are in good condition, and toileting facilities are in sanitary and operating condition. There are bins for solid waste. The floors appeared clean throughout the facility. LPA observed smoke and carbon monoxide detectors, and a fire extinguisher. Nap equipment was stored appropriately with bedding separated. LPA observed documentation of sign in and sign outs and documentation that facility is conducting emergency disaster drills at least every 6 months. Per record the last fire drill was conducted on 3/24/2025.

Children have access to water indoors and outdoors by using cups and a water jug that is filled in the classroom. Playground equipment and surfaces were inspected and are in good condition, with enough resilient material under climbing structures to absorb a fall. There are no firearms or bodies of water on the premises. Representative stated there are no poisons on the premises.

LPA reviewed present staff files. At least one staff member present today has current Pediatric CPR and First Aid certification. (Report continues 809-C)

NAME OF LICENSING PROGRAM MANAGER: Seychelle De Luca
NAME OF LICENSING PROGRAM ANALYST: Mandie Goodwin
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/24/2025 03:24 PM - It Cannot Be Edited


Created By: Mandie Goodwin On 04/23/2025 at 09:21 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CAMELLIA PRESCHOOL
FACILITY NUMBER: 343616702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101212(b)
Reporting Requirements
(b) The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s).

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 by not reporting the name of the center director to the Department which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Facility will designate the on-site director that oversees the classroom and send the name of director and a complete director packet to the department by the above POC date.
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.
Seychelle De Luca
NAME OF LICENSING PROGRAM MANAGER:
Mandie Goodwin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2025 03:24 PM - It Cannot Be Edited


Created By: Mandie Goodwin On 04/23/2025 at 09:32 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CAMELLIA PRESCHOOL
FACILITY NUMBER: 343616702

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
WD
101700.3(b)(1)
WD- 101700(b)(1) California Lead Action Level at Child Care Centers (b) Testing results with ... (1) ... "values of 5.5 ppb or greater shall be deemed an Action Level Exceedance.

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 as evidenced by test results indicated an Action Level Exceedance (ALE) of 6.7 ppb in samples collected from the drinking fountain in the lobby which poses/posed a potential health, safety, or personal rights risk to children in care if not corrected
POC Due Date: 05/23/2025
Plan of Correction
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Facility Representative stated the faucet is not in use by the preschool children. Alternate water is available from other sources that have not tested in exceedance.
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.
Seychelle De Luca
NAME OF LICENSING PROGRAM MANAGER:
Mandie Goodwin
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2025


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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CAMELLIA PRESCHOOL
FACILITY NUMBER: 343616702
VISIT DATE: 04/23/2025
NARRATIVE
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LPA observed immunization records and documentation of the educational background, training, and/or experience of staff. Upon review, all staff members had current mandated reporter trainings. LPA advised AB 1207 Mandated Reporter training must be renewed every two years and can be renewed at www.mandatedreporterca.com.

A sample of 3 children's records were reviewed. Each child's file contained an emergency card, consent for emergency medical treatment, health history, a record of immunization’s, and notifications of personal and parent’s rights.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Director was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

On 3/7/2025, a water sample taken from a drinking fountain in the lobby was collected and tested for the presence of lead. The test results indicated lead values of 6.7 parts per billion (pbb), exceeding the recommended 5.5 pbb. Facility representative stated that the preschool children do not use the lobby water. The water used for the classroom was previously tested in 2022 and has not tested for a lead exceedance.

LPA referred licensee to the Department website for lead: Lead Toxicity Prevention and Water Testing Information- https://www.cdss.ca.gov./inforesources/child-care-licesing/water-testing-information

LPA discussed the safe sleep regulations with Director and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Seychelle De Luca
NAME OF LICENSING PROGRAM ANALYST: Mandie Goodwin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CAMELLIA PRESCHOOL
FACILITY NUMBER: 343616702
VISIT DATE: 04/23/2025
NARRATIVE
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LPA also informed Director of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Representative was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the facility representative Reena Sharma. Based on the areas evaluated, title 22 deficiencies were cited today and are listed on the 809-D. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Seychelle De Luca
NAME OF LICENSING PROGRAM ANALYST: Mandie Goodwin
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
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