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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455408410
Report Date: 05/01/2024
Date Signed: 05/03/2024 09:42:29 AM

Document Has Been Signed on 05/03/2024 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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:SHASTA HEAD START-SHASTA LAKEFACILITY NUMBER:
455408410
ADMINISTRATOR/
DIRECTOR:		ANNA WEDDING-JACKMANFACILITY TYPE:
860
ADDRESS:1650 STANTON DRIVETELEPHONE:
(530) 241-1036
CITY:SHASTA LAKESTATE: CAZIP CODE:
96019
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 0DATE:
05/01/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Tessa BuelTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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A prelicensing inspection was conducted today, May 1, 2024 at 10:15am by Licensing Program Analyst (LPA), Snow. LPA met with applicant Tesa Buell. The applicant/licensee is requesting a license for 8 infants 8 toddlers and 20 preschool children for total capacity of 36. The facility will operate Monday-Friday, 7:30 to am to 4:00pm. The facility has 3 rooms, each room has its own attached bathroom.

The indoor and outdoor activity spaces were toured, and the facility sketch was verified. The Kitchen is off limits to children by means of a door lock. There is a full kitchen (refrigerator, stove, sink) to store/prepare meals. The facility plans to prepare and serve breakfast, lunch, and snack. The isolation area for sick children will be located in the director’s office.

Infants will be in the INFANT/TODDLER BUILDING in Room ESLA. There are 2 sinks and 2 toilets for the infants along with a changing table and nap room with 4 cribs. An infant capacity worksheet was completed during the visit. The room measured for 886 square feet which is enough indoor space for the requested number of infants. Based on the above, the maximum capacity of infants is 8.

Toddlers will be in the INFANT/TODDLER BUILDING in Room ESLB. There are 2 sinks and 2 toilets in the room. A toddler capacity worksheet was completed during the visit and there is enough indoor space (950 square ft) for the requested number of toddlers. Based on the above, the maximum capacity of toddlers is 8.

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SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: SHASTA HEAD START-SHASTA LAKE
FACILITY NUMBER: 455408410
VISIT DATE: 05/01/2024
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Preschoolers will be in the Main BUILDING in Room SLCA. There are 2 sinks and 2 toilets in the room. A preschool capacity worksheet was completed during the visit and there is enough indoor space (1078 square ft) for the requested number of preschoolers. Based on the above, the maximum capacity of preschoolers is 20.

Shared play yard. The facility currently has one play yard with no climbing structures. They are requesting a waiver for infants, toddlers, and preschool to use this yard. A capacity worksheet was completed during the visit to measure the play yard measures 2,389.75 square feet which is not enough square footage for the full capacity.

*Proposed play yard. (In the future the facility plans to install a separate preschool yard and a combined infant/toddler yard/ applicant said this will be completed approximately September of 2024)

The outdoor play area is fully fenced. There are no climbing structures. There is only a blacktop surface and a pop-up shade structure. A safe surface for the infants to crawl will be required. There is no pool, spa, pond, fountain, or any other body of water on the premises.

The poisons are locked in a storage room. There is safe and age appropriate furniture, toys, and play equipment available for children.

Applicant, Tessa Buell 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, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

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SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: SHASTA HEAD START-SHASTA LAKE
FACILITY NUMBER: 455408410
VISIT DATE: 05/01/2024
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This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) tollfree ADA Information Line at (800) 514-0301 (voice) or (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.

LPA reviewed with applicant, Tessa Buell the LIC 311A, Records to Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.
LPA discussed the safe sleep regulations with applicant, Tessa Buell and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep, as an additional resource. LPA also informed [applicant, Tessa Buell 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.

[Applicant, or Licensee] was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Exit interview conducted and report was reviewed with the applicant, Tessa Buell.


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SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: SHASTA HEAD START-SHASTA LAKE
FACILITY NUMBER: 455408410
VISIT DATE: 05/01/2024
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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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.


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

1. Managerial approval (additional documents may be required)
2. Waiver approval for the shared yard.
3. A cushioned surface appropriate for infant play.
4. Updated Job descriptions
5. Resolution naming the director
6. LIC 403 Balance Sheet (in the name of the corp)
7. LIC 404 Financial release & verification (in the name of the corp)
8. Family Handbook & personnel policy/training review
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4