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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393610932
Report Date: 06/10/2022
Date Signed: 06/10/2022 11:35:27 AM

Document Has Been Signed on 06/10/2022 11:35 AM - 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:CAPC-CENTRAL 1FACILITY NUMBER:
393610932
ADMINISTRATOR:KIM PAWLOWICZFACILITY TYPE:
850
ADDRESS:540 N. CALIFORNIA ST.TELEPHONE:
(209) 644-5323
CITY:STOCKTONSTATE: CAZIP CODE:
95202
CAPACITY: 24TOTAL ENROLLED CHILDREN: 16CENSUS: 13DATE:
06/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Moma SyhachackTIME COMPLETED:
11:48 AM
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On Friday, June 10, 2022, at 09:05am, Licensing Program Analyst (LPA) Elvira Sierra met with Moma Syhachack for the purpose of an unannounced annual inspection. Facility is a combination center with a preschool and infant program on site. Facility operates in classroom #136 Monday through Friday from 7:00 AM to 5:30 PM year round. Upon arrival present in the facility were 13 preschool children supervised by three staff members who all have obtained a criminal record clearance through Community Care Licensing. Facility is operating within the capacity and in compliance with staff child ratio on this day.

LPA inspected all activity and classroom spaces, restrooms, food service, and outdoor play areas for Health and Safety hazards. All mandatory postings are posted by the main entrance of the facility. Classroom is adequately ventilated. The floors appeared clean throughout the facility. Classroom has age appropriate toys and equipment that are in good repair. Restrooms were observed clean, in good repair and with adequate supplies. Cleaning products and Toxins are maintained inaccessible to children. First Aid Kit is maintained and properly stocked. Center Manager stated currently no children are on medication. LPA observed at least one functional smoke/carbon monoxide detector and a fully charged 2A:10BC fire extinguisher. Facility has a working telephone at the site. Center Manager stated there are no poisons, or firearms on the premises. No bodies of water were observed. Outdoor activity space surface is free of any hazard and areas around high climbing equipment have cushioning material to absorb falls. Facility offer drinking water by using water dispenser and disposable cups. Facility provides breakfast, lunch and snack to children in care and are prepared at the main kitchen and is delivery twice a week. Menus are posted, updated and available for public view.

At 10:30am 10 children and three staff files were reviewed. Children and staff files were completed and contained the required documentation by regulation. At least one staff member present today has current Pediatric CPR and First Aid certification. Facility uses an electronic application for parents to sign/in-sign/out. Last Emergency Drill was conducted on 06/10/22 and is properly logged. ----Report continues on subsequent page 809C

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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: CAPC-CENTRAL 1
FACILITY NUMBER: 393610932
VISIT DATE: 06/10/2022
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Center Manager 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulations and Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, a Plan for Providing 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)/ (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

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.

A Notice of Site Visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Notice of Site Visit was posted by LPA. Exit interview conducted and report was reviewed with the Center Manager, Moma Syhachack.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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