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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393608039
Report Date: 06/15/2021
Date Signed: 06/15/2021 12:36:39 PM

Document Has Been Signed on 06/15/2021 12:36 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:ST. PETER'S PRESCHOOLFACILITY NUMBER:
393608039
ADMINISTRATOR:HUST, JANFACILITY TYPE:
850
ADDRESS:50 S. LOWER SACRAMENTO RDTELEPHONE:
(209) 368-5929
CITY:LODISTATE: CAZIP CODE:
95242
CAPACITY: 72TOTAL ENROLLED CHILDREN: 0CENSUS: 27DATE:
06/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Jan HustTIME COMPLETED:
12:45 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
Licensing Program Analyst (LPA) Justin Denton met with Director Jan Hust to discuss the unusual incident report filed by the facility staff to Community Care Licensing (CCL) on 05/21/21.

During today's inspection, LPA observed the outdoor play area of the facility where the incident occurred on the morning of 5/21/21. Director Hust also briefed LPA Denton on the new procedures installed after the incident to protect the health and safety of children.

Information obtained during the inspection and the incident report revealed that a child was left outside on the playground for about 75 minutes, from 9:00 to about 10:15 AM. The child left the line of children when the two staff present were focused on a commotion involving two other children. When the class proceeded to the gym, the child was left behind on the playground alone.

This is a violation of Title 22 Section 101229(a)(1) and will be cited. Immediate civil penalty will be assessed.

Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.

Deficiencies issued during today's case management incident visit. Notice of Site visit posted and exit interview conducted.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Justin L Denton
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2021
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 06/15/2021 12:36 PM - It Cannot Be Edited


Created By: Justin L Denton On 06/15/2021 at 12:04 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: ST. PETER'S PRESCHOOL
FACILITY NUMBER: 393608039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2021
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). This requirement was not met as evidenced by:

Staff and management admitted that a child
1
2
3
4
5
6
7
Director Hust provided LPA with a copy of new procedures put in place to ensure smooth transitions from outside to inside. The two staff present during the incident are no longer employed with the facility. LPA is not requiring any further plan of correction at this time.

Civil penalty assessed.
8
9
10
11
12
13
14
was left on the playground alone during transition from the playground to the gym. Child was left alone without supervision for approximately 75 minutes.

This is an immediate risk to the health and safety of children 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:Jeanne Smith
LICENSING EVALUATOR NAME:Justin L Denton
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2