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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393617385
Report Date: 07/21/2021
Date Signed: 07/21/2021 12:21:08 PM

Document Has Been Signed on 07/21/2021 12:21 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:ACE TOTS PRESCHOOLFACILITY NUMBER:
393617385
ADMINISTRATOR:KHAN, NADIAFACILITY TYPE:
850
ADDRESS:7204 SHORELINE DRIVETELEPHONE:
(209) 330-1030
CITY:STOCKTONSTATE: CAZIP CODE:
95219
CAPACITY: 90TOTAL ENROLLED CHILDREN: 0CENSUS: 24DATE:
07/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Nadia KhanTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Fabiola Diaz met with Site Supervisor on 7/21/2021 for the purpose of a case management inspection. Census at the time of inspection was 24 children and 5 staff. COVID-19 precautionary measures were implemented during this visit by LPA. On today's date, LPA observed some staff not wearing masks, and staff stated there was a misunderstanding of the mask mandate by the State of California. LPA discussed the current COVID-19 guidance for day care facilities regarding mask wearing and issued a Technical Assistance note. LPA provided PIN-21-18-CCP to Site Supervisor.

LPA was informed by Site Supervisor that the Department was not notified of on an unusual incident involving Child 1 (C1) on 5/4/2021, within the next working day nor submitted a written report within 7 days. C1 was injured and was seen by a doctor. Staff and parent interviews confirmed that Parent 1 did not receive a written incident to sign. Admission Agreement states “…The incident report MUST be signed by the parent/guardian and returned to your child’s teacher…” Admission agreement also states “If a parent fails to notify the preschool of their child’s absence for two weeks or if tuition is not paid within 2 weeks after the due date, the child will only be re-admitted after paying the balance due and registration fee of $75.00” and “A minimum of two-week written notice in advance is required before a child can be withdrawn from preschool…” Based on parent and staff interviews, LPA was informed that Parent 1 notified Site Supervisor of C1's return date within 2 weeks after the incident on 5/4/21. LPA was also informed that Parent 1 did not submit a 2 week notice to withdraw C1 from preschool. However, facility still terminated services to C1. Facility did not ensure to comply with the policies on their admission agreement.
During children's files review, LPA observed C2's and C3's files to be missing or have incomplete Physician's Reports LIC 701 and immunization records. Site Supervisor stated today that C3 and C2 are no longer attending the facility. Technical Violation notes were discussed with Site Supervisor regarding regulations on children's immunization records and Physician's Reports.
The following Title 22 Deficiencies are being cited on the subsequent 809-D pages. Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Fabiola Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2021
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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Document Has Been Signed on 07/21/2021 12:21 PM - It Cannot Be Edited


Created By: Fabiola Diaz On 07/21/2021 at 10:40 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: ACE TOTS PRESCHOOL
FACILITY NUMBER: 393617385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/23/2021
Section Cited
CCR
101212(d)

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101212 Reporting Requirements d) Upon the occurrence…of any of the events…a report shall be made to the Department…within the Department's next working day…a written report containing the information…shall be submitted…within seven days following the occurrence of such event. This requirement was not met as
evidenced by:
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Site Supervisor stated she faxed in the written Unusual Incident Report on 6/8/21. On today's date LPA also received a copy of the written Unusual Incident Report.
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Based on observation and interview, licensee did not ensure to notify the Department on an unusual incident involving C1 within the next working day and submit a written report within 7 days.
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Type B
07/23/2021
Section Cited
CCR101219(f)

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101219 Admission Agreements (f) The licensee shall comply with all terms and conditions set forth in the admission agreement. This requirement was not met as
evidenced by:
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Site Supervisor or licensee will submit a written statement explaining how the facility staff will ensure to abide by their admission agreements, and how it will continue from today's date forward.
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Based on observation and interview, licensee did not ensure to comply with the policies on the admission agreement.
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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:Jeanne Smith
LICENSING EVALUATOR NAME:Fabiola Diaz
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2021


LIC809 (FAS) - (06/04)
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