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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624247
Report Date: 01/07/2025
Date Signed: 01/07/2025 06:52:56 PM

Document Has Been Signed on 01/07/2025 06:52 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:EXCELSIOR PRESCHOOL GOLD RIVER LLCFACILITY NUMBER:
343624247
ADMINISTRATOR/
DIRECTOR:		FUGATE, NANCYFACILITY TYPE:
850
ADDRESS:2317 GOLD MEADOW WAYTELEPHONE:
(916) 730-8757
CITY:GOLD RIVERSTATE: CAZIP CODE:
95670
CAPACITY: 118TOTAL ENROLLED CHILDREN: 118CENSUS: 42DATE:
01/07/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Michelle IngramTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst Erwina Pascual-Golamco (LPA) met with Facility Representative (FR) Michelle Ingram, for an unannounced annual inspection of this preschool facility. LPA toured the facility, including all activity and classroom spaces, restrooms, and outdoor play area. FR was reminded never to exceed the conditions, limitations and capacity specified on the license. Facility hours of operation are Monday to Friday, 7:00 AM to 6:00 PM.

FR 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.

Classrooms observed are in good repair and free of hazards with heating and ventilation for safety and comfort. The facility has equipment and age-appropriate materials for children. Bathrooms were sanitary, sinks and toilets were in operating condition. Playground equipment and surfaces were inspected and are in good condition with enough resilient material under climbing structures to absorb a fall. Uncontaminated drinking water was readily available to children both indoors and outdoors. LPA observed a posted menu. The facility provides breakfast, lunch, and snacks.

There are no firearms or bodies of water on the premises and the facility has at least one functioning smoke and carbon monoxide detector. LPA observed required licensing documentation was posted for parental review. LPA observed that parents are signing their children in and out of the center electronically.



continued on LIC809-C...
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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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: EXCELSIOR PRESCHOOL GOLD RIVER LLC
FACILITY NUMBER: 343624247
VISIT DATE: 01/07/2025
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LPA reviewed with FR the LIC311A, Records to Be Maintained at The Facility, for child's records, personnel records, administrative records, and documents to be posted. Sample of children and staff files were reviewed. LPA did not observe LIC9224 Acknowledgement of Receipt of Licensing Reports in sample children files for dates 07/02/24 and 11/26/24. LPA reviewed staff transcripts and observed staff caring for children were qualified. At least one staff had a current Pediatric CPR and First Aid certification. Staff have current Mandated Reporter certificates and proof of immunization. LPA observed a fire drill log. There is First Aid equipment available.

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/.

CCC COMPLETED TESTING AND NO LEAD EXCEEDANCES. Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP. LPA referred FR to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.


continued on LIC809-C...
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
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: EXCELSIOR PRESCHOOL GOLD RIVER LLC
FACILITY NUMBER: 343624247
VISIT DATE: 01/07/2025
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FR was informed of the https://mychildcareplan.org/; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

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.

A deficiency was cited during today's inspection. This report was reviewed with FR, and an exit interview was conducted. Appeal Rights and A Notice of Site Visit (NOS) was provided to FR, who will post it for a period of 30 days for parental review.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/07/2025 06:52 PM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 01/07/2025 at 02:01 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: EXCELSIOR PRESCHOOL GOLD RIVER LLC
FACILITY NUMBER: 343624247

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8595(c)(4)
ยง1596.8595 Posting licensing report by child care facility or home; duration of posting; civil penalty for failure to comply; reports to be provided to parents or guardian of each child receiving services (c)(4) The licensee shall keep verification of receipt in each child's file.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 5 out of 5 sample children's files did not have LIC9224 for report dates 07/2/24 and 11/26/24, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2025
Plan of Correction
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Director stated she will provide the LIC9224 reports to parents/authorized representatives by 5PM POC due date, and will email LPA attestation statement that it is complete, and receipt in children's files. If Director needs more time, she will email LPA.
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.
SUPERVISOR'S NAME:Natalie Dunaway
LICENSING EVALUATOR NAME:Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


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