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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624040
Report Date: 10/26/2022
Date Signed: 10/26/2022 12:31:30 PM

Document Has Been Signed on 10/26/2022 12:31 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:SACRAMENTO WALDORF SCHOOL EARLY CHILDHOODFACILITY NUMBER:
343624040
ADMINISTRATOR:MACK, ASHLEYFACILITY TYPE:
850
ADDRESS:3750 BANNISTER RDTELEPHONE:
(916) 961-3900
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 15TOTAL ENROLLED CHILDREN: 15CENSUS: 14DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Ashley MackTIME COMPLETED:
01:00 PM
NARRATIVE
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On October 26, 2022 Licensing Program Analyst (LPA) Lea Habtom met with Director, Ashley Mack, for the purpose of an unannounced required 1 year inspection. Operating hours of the facility are from 8:00 am- 12:00pm and 12:30 pm- 5:00 pm Monday thru Friday. Director guided LPA on a tour of the facility, at which time a census of 14 preschool children supervised by 2 staff was observed.

All individuals subject to criminal background review have obtained criminal record clearance. Director 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.

A health and safety inspection was conducted in the classrooms, restrooms, food service areas, and outdoor play areas. LPA observed the following documents are posted: License, Emergency Disaster Plan, Personal Rights, Parents' Rights Poster, menus, and daily schedule. Cleaning disinfectants and hazardous items are appropriately stored and inaccessible to children. Medication was not stored inaccessible to children. LPA made director aware and Director moved medication up high to have it inaccessible. Director stated there are no poisons on the premises. Furniture and equipment are in good condition, and toileting facilities are in safe, sanitary, and operating condition. There is a porta potty by the back patio and school restrooms are accessible to day care children. The floors appeared clean throughout the facility. The facility provides afternoon snack and another snack for children who stay late and lunch is provided by the parents. The food preparation space is free of litter and all food was protected against contamination. Drinking water was readily available to children both indoors and outdoors via drinking fountains and labeled bottles. Facility uses an paper sign in and sign out. LPA observed full legal signatures of authorized representatives. There are no firearms or bodies of water on the premises. LPA observed a functional carbon monoxide detector. Playground equipment and surfaces are free of loose or sharp

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Lea Habtom
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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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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: SACRAMENTO WALDORF SCHOOL EARLY CHILDHOOD
FACILITY NUMBER: 343624040
VISIT DATE: 10/26/2022
NARRATIVE
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parts. LPA observed wood chip cushioning beneath the play structure. Sand box is covered with a tarp when not in use. Outdoor shade is provided by trees and awnings.

Staff files were reviewed. At least one staff member present today has current Pediatric CPR and First Aid certification. Immunization records were missing for one staff member. Documentation of the educational background, training, and/or experience and AB 1207 Mandated Reporter training certificates were verified.

Children's records were reviewed. Each child's file contained an emergency card, consent for emergency medical treatment and notifications of children’s and parent’s rights, health history, physician's report and immunization records. LPA observed signed form LIC224 Acknowledgement of receipt of licensing reports.

This facility provides Incidental Medical Services – IMS. A plan of operation is on file at the facility. 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 Child Care Centers Sections 101173 and 101226.

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.

LPA verified the annual fees are current. A staff interview was conducted with the Director, Ashley Mack.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Title 22 Deficiency has been cited on the attached LIC 809-D. LPA Lea Habtom informed director Ashley Mack that this report dated October 26, 2022 documents 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 Lea Habtom informed the director Ashley Mack to provide a copy of this licensing report dated October 26, 2022 that documents any Type A citation 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. Appeal Rights given.

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Lea Habtom
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/26/2022 12:31 PM - It Cannot Be Edited


Created By: Lea Habtom On 10/26/2022 at 11:43 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: SACRAMENTO WALDORF SCHOOL EARLY CHILDHOOD
FACILITY NUMBER: 343624040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
101226(e)(1)(A)
Health-Related Services
(e) In centers where the licensee chooses to handle medications: (1) All prescription and nonprescription medications shall be centrally stored in accordance with the requirements specified below: (A) Medications shall be kept in a safe place inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the director did not comply with the section cited above in that the medication located was accessible to children which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2022
Plan of Correction
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LPA made director aware to store all medication inaccessible to children. Medication was moved to a higher location and deficiency was cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Lea Habtom
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/26/2022 12:31 PM - It Cannot Be Edited


Created By: Lea Habtom On 10/26/2022 at 11:43 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: SACRAMENTO WALDORF SCHOOL EARLY CHILDHOOD
FACILITY NUMBER: 343624040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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 that a staff member did not have proof of measles and pertussis on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Director agreed to provide proof of immunizations via email to LPA L. Habtom by POC date.
Type B
Section Cited
CCR
101217(d)
Personnel Records
(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the director did not comply with the section cited above in that staff files are missing LIC 508, LIC 503, LIC 9108 and LIC 9052 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/28/2022
Plan of Correction
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Director agreed to provide proof of forms via email to LPA L. Habtom by POC date.
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:Lea Habtom
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/26/2022 12:31 PM - It Cannot Be Edited


Created By: Lea Habtom On 10/26/2022 at 11:43 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: SACRAMENTO WALDORF SCHOOL EARLY CHILDHOOD
FACILITY NUMBER: 343624040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101226(e)(3)(B)
Health-Related Services
(3) Prescription medications may be administered if all of the following conditions are met: (B) For each prescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, in that there was an epipen with no label instructions provided by the parent and no box with physician instruction which which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2022
Plan of Correction
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Director agreed to provide proof of box with physicians instructions and written authorization from parents to LPA L. Habtom via email by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Lea Habtom
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022


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