<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624917
Report Date: 02/12/2025
Date Signed: 02/12/2025 03:45:41 PM

Document Has Been Signed on 02/12/2025 03:45 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:MISSION AVENUE PRESCHOOLFACILITY NUMBER:
343624917
ADMINISTRATOR/
DIRECTOR:		CHRISTINA DIAZ BUSHMANFACILITY TYPE:
850
ADDRESS:2433 MISSION AVENUETELEPHONE:
(916) 487-4647
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 44TOTAL ENROLLED CHILDREN: 44CENSUS: 21DATE:
02/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Nicole EstradaTIME VISIT/
INSPECTION COMPLETED:
04:00 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 Wednesday, February 12, 2025, at approximately 1:30 PM Licensing Program Analyst (LPA) Josiah Gathing and Staff Attorney Adam Bentley met with Director Nicole Moran-Estrada, to follow up on a self-reported Unusual Incident submitted to Licensing on February 10, 2025. According to the Unusual Incident Report (UIR), a child attempted to hit a teacher and the teacher grabbed the child by the arm and sat him down. LPA conducted interviews and reviewed a video record. Staff stated in interview that the teacher was terminated after video of the incident was reviewed. Staff stated in interview that they did not have previous concerns about the teacher's treatment of children. LPA reviewed video footage of the incident. The footage showed a teacher grabbing a child near the wrists and walking him backward after the child attempted to hit the teacher. An administrator entered the room, crouched next to the child, and spoke with the child. The child then attempted to strike the teacher again and when the teacher grabbed the child again the child dropped to the floor and the administrator intervened. Upon reviewing this footage and conducting interviews, LPA determined that the incident violated the personal rights of the child.
Therefore, based on record review and interview, the preponderance of evidence standard has been met, and the allegation is substantiated. An exit interview was conducted and a notice of site visit provided. Notice of site visit shall remain posted for 30 days.

Title 22 deficiencies are cited on the subsequent pages of this report. Director acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809-D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 and Appeal Rights were provided. Director's signature on this report acknowledges receipt of these rights. This report was reviewed with the Director. An exit interview was conducted. A Notice of Site Visit was provided and shall remain posted for a period of 30 days.

Continued on LIC 809-C...
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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
Document Has Been Signed on 02/12/2025 03:45 PM - It Cannot Be Edited


Created By: Josiah Gathing On 02/12/2025 at 02:48 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: MISSION AVENUE PRESCHOOL
FACILITY NUMBER: 343624917

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2025
Section Cited
CCR
101223(a)(3)

1
2
3
4
5
6
7
101223 Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights: (3) To be free from corporal or unusual punishment, infliction of pain...
The above requirement was not met as evidenced by:
1
2
3
4
5
6
7
Staff member was terminated from employment prior to inspection and citation is cleared.
Staff will conduct Personal Rights training and provide LPA with training itinerary.
8
9
10
11
12
13
14
Based on interviews and record review the facility did not comply with the above regulation as staff handled a child in a rough manner which poses Health, Safety, or Personal Rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Seychelle De Luca
LICENSING EVALUATOR NAME:Josiah Gathing
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MISSION AVENUE PRESCHOOL
FACILITY NUMBER: 343624917
VISIT DATE: 02/12/2025
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
26
27
28
29
30
31
32
Upon receipt, Director shall post and provide copies of this licensing report to parents/ guardians of children who are currently enrolled as well as parents/ guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must acknowledge receipt of this report and citation by signing a LIC9224, “ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS”. A copy of this form should be placed in each child file upon receipt from parent.

LPA discussed this report with Director and conducted an exit interview. LPA also provided appeal rights.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Josiah Gathing
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3