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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455408092
Report Date: 08/17/2022
Date Signed: 08/19/2022 09:42:34 AM

Document Has Been Signed on 08/19/2022 09:42 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:SHASTA HEAD START - BURNEYFACILITY NUMBER:
455408092
ADMINISTRATOR:PFADT, TANAKAFACILITY TYPE:
850
ADDRESS:37461 BAILEY AVENUETELEPHONE:
(530) 510-4665
CITY:BURNEYSTATE: CAZIP CODE:
96013
CAPACITY: 20TOTAL ENROLLED CHILDREN: 13CENSUS: 0DATE:
08/17/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tanaka Pfadt, Site Supervisor TIME COMPLETED:
12:30 PM
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A prelicensing inspection was conducted today at 10:30 a.m. by Licensing Program Analyst (LPA), N. Cunningham. LPA met with Site Supervisor, T. Pfadt. The applicant is requesting a license for 20 preschool age children. The facility will operate mid August – early June, Monday-Friday, 8:30 a.m. to 2:30 p.m. The facility has one classroom and one bathroom for children and one bathroom for staff in the staff break room.

The indoor and outdoor activity spaces were toured, and the facility sketch was verified. Meals will be prepared in the kitchen. Children will nap on cots in the classroom. The isolation area for sick children will be located in the office area.

The outdoor play area is fully fenced. There is a play structure for children to play on and adequate cushioning underneath. There is no pool, spa, pond, fountain, or any other body of water on the premises. There is safe and age appropriate furniture, toys, and play equipment available for children.

A capacity worksheet was completed during the visit. There is enough indoor space for 20 children. There are two toilets and three sinks available for children.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Nicolette Cunningham
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: SHASTA HEAD START - BURNEY
FACILITY NUMBER: 455408092
VISIT DATE: 08/17/2022
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LPA reviewed the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

Facility representative was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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.

LPA discussed the safe sleep regulations with applicant/licensee/facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant/licensee/facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

The following items need to be completed prior to the granting of license:

1. Receipt of approved fire clearance on form STD850 with correct address
2. Proof of completion for preventative health and safety

Exit interview conducted and report was reviewed with the Site Supervisor T. Pfadt.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Nicolette Cunningham
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
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