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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 550308991
Report Date: 05/01/2024
Date Signed: 05/07/2024 09:42:53 AM

Document Has Been Signed on 05/07/2024 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:SOULSBYVILLE PM CLUBFACILITY NUMBER:
550308991
ADMINISTRATOR/
DIRECTOR:		JULIE DUARTEFACILITY TYPE:
840
ADDRESS:20300 SOULSBYVILLE ROADTELEPHONE:
(209) 768-3562
CITY:SOULBYVILLESTATE: CAZIP CODE:
95372
CAPACITY: 100TOTAL ENROLLED CHILDREN: 100CENSUS: 18DATE:
05/01/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Site Supervisor, Julie DuarteTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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On May 1, 2024, Licensing Program Analyst (LPA) Lauren Scott met with Site Supervisor, Julie Duarte for the purpose of an unannounced annual inspection. Facility days and hours of operation are Monday-Friday from 12:00 PM to 5:30 PM. There were 18 children present at the start of today's inspection. LPA reviewed the sign in/out book and observed that the children are properly signed in.

Licensee was reminded that all adults 18 and over, 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.

LPA toured the facility inside and out. LPA observed that hazardous items were inaccessible to children in care. LPA reviewed staffing ratios, first aid supplies, fire drills and drinking water. LPA observed all required forms to be posted. LPA discussed locating a functioning carbon monoxide and smoke alarms in the classroom. LPA observed the toys, furniture and equipment to be in good condition. Outdoor play area was toured. Facility provides snack to children in care.

LPA reviewed children’s and staff files. LPA observed health screening reports and discussed the requirement of immunization's for all staff and children. LPA discussed the requirement for at least one staff member present to have current Pediatric CPR and First Aid. LPA discussed the requirement for all staff to have a valid AB1207 Mandated Reporter training certificate. The site supervisor was reminded to renew the course every 2 years through www.mandatedreporterca.com website.

Report continues on 809-C

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
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.

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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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SOULSBYVILLE PM CLUB
FACILITY NUMBER: 550308991
VISIT DATE: 05/01/2024
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/

LPA referred licensee to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

Licensee was informed of the MyChildCarePlan.org website; 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.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Exit interview conducted and report was reviewed with the licensee, Julie Duarte. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements may result in an immediate civil penalty of $100.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
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
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Document Has Been Signed on 05/07/2024 09:42 AM - It Cannot Be Edited


Created By: Lauren Scott On 05/01/2024 at 02:41 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SOULSBYVILLE PM CLUB
FACILITY NUMBER: 550308991

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, 3 out of 4 staff did not have all immunizations on file for review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Facility will submit copies of all required immunizations to LPA via email by POC date
LAUREN.SCOTT@DSS.CA.GOV
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, where 2 out of 4 staff did not have a valid Mandated Reporter Training certificate on file for review, which posesd a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Facility will submit copies of valid Mandated Reporter Training certificates to LPA by POC due date via email

LAUREN.SCOTT@DSS.CA.GOV
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:Chayntel Hunter
LICENSING EVALUATOR NAME:Lauren Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2024


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