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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 503808988
Report Date: 12/08/2021
Date Signed: 12/08/2021 02:43:22 PM

Document Has Been Signed on 12/08/2021 02:43 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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:HAZEL'S CHRISTIAN PRESCHOOL&CHILD CARE CENTER IIFACILITY NUMBER:
503808988
ADMINISTRATOR:DOMSON, HAZELFACILITY TYPE:
850
ADDRESS:1528 OAKDALE RDTELEPHONE:
(209) 521-4422
CITY:MODESTOSTATE: CAZIP CODE:
95355
CAPACITY: 37TOTAL ENROLLED CHILDREN: 37CENSUS: DATE:
12/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
03:00 PM
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On 12/08/2021 Licensing Program Analyst (LPA) Nancy Her, conducted an unannounced Annual Required Inspection for the preschool license. LPA met with Director, Hazel Domsom, and toured the facility indoors and outdoors. Days and hours of operation are Monday through Friday 6:00 am to 7:00pm.

There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition allowed or stored on the premises. Disinfectants, cleaning solutions, medication and other hazardous items are made inaccessible. No poisons were observed during the inspection.

Furniture and equipment are in good condition, free of sharp, loose or pointed parts. Playground equipment is in safe condition, free of sharp, loose or pointed parts. The surface of the outdoor activity space is maintained in a safe condition and is free of hazards. All toilets and handwashing facilities are in safe and sanitary operating condition. Floors in the facility are clean and safe. The center provides 2 snacks. Parents are required to bring their children food. All food is protected against contamination and any contaminated food is discarded immediately. Solid waste storage containers have tight-fitting covers and are in good repair. Drinking water is available both indoors and outdoors. Areas around high climbing equipment, swings and slides have cushioning material to absorb falls. The facility is free of flies, insects and rodents. Facility has one or more functioning carbon monoxide detectors that meet statutory requirements.

Facility representative 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.

Continued on 809-C
SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Nancy Her
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: HAZEL'S CHRISTIAN PRESCHOOL&CHILD CARE CENTER II
FACILITY NUMBER: 503808988
VISIT DATE: 12/08/2021
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Capacity and limitations as specified on the license are being maintained. At least one person trained in CPR and Pediatric First Aid is present when children are at the facility or at offsite activities. The name of the child care center director or fully-qualified teacher(s) designated to act in the director’s absence has been reported to the Department. The person who signs the child in/out of the facility shall use their full legal signature and record the time of day. All children are under supervision, including visual supervision, of a teacher at all times. Facility maintains a ratio of one teacher supervising no more than 12 children in care. LPA reviewed a sample of children’s files and observed files were complete with contact information for authorized representative and or relatives or others who can assume responsibility for the child and medical assessment. LPA reviewed a sample of staff files and observed files were complete with health screening, immunization records for influenza, pertussis and measles and current documentation of completed mandated reporter training. Menus are posted at least one week in advance where an authorized representative can view them.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.

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.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D) Licensee was provided a copy of their appeal rights.

Exit interview conducted and report was reviewed with the facility representative Hazel Domsom.
A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Duane Matsubara
LICENSING EVALUATOR NAME: Nancy Her
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
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Document Has Been Signed on 12/08/2021 02:43 PM - It Cannot Be Edited


Created By: Nancy Her On 12/08/2021 at 02:21 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: HAZEL'S CHRISTIAN PRESCHOOL&CHILD CARE CENTER II
FACILITY NUMBER: 503808988

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
101239(o)
Playground equipment shall be securely anchored to the ground unless it is portable by design.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. During today's inspection, LPA was able to lift playground dome off the ground which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/22/2021
Plan of Correction
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Licensee wil have playground domes be inaccessible to children until playground domes are anchored into the ground. Licensee will anchor the playground domes and submit verification to Fresno Community Care Licensing by 12/22/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Duane Matsubara
LICENSING EVALUATOR NAME:Nancy Her
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2021


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