Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313610190
Report Date: 06/12/2017
Date Signed 06/12/2017 02:44:26 PM

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:ADVENTURE CLUB-THOMAS JEFFERSONFACILITY NUMBER:
313610190
ADMINISTRATOR:SALCI, CAROLFACILITY TYPE:
840
ADDRESS:750 CENTRAL PARK DRIVETELEPHONE:
(916) 774-5169
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:60CENSUS: 45DATE:
06/12/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Brianna Schmidt Assistant DirectorTIME COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Amanda Blesi met with assistant director Brianna Schmidt for a random annual inspection. This facility is located on Thomas Jefferson Elementary School grounds in Portable 1 and 2. LPA toured the facility including all activity/classroom areas, the isolation area, and food service area. LPA reviewed care and supervision of children, staffing ratios, health related services, furniture, equipment, drinking water and food service provisions. The facility uses the elementary school playground and the elementary school bathrooms. There were 45 school age children present along with four teachers, three aids and the assistant director.

LPA reviewed the children's Identification and Emergency Information. LPA reviewed personnel's education and immunization requirements. All staff currently employed with the center have criminal record clearances and are associated to the Fiddyment Farms site facility # 313622270 waiver on file. At least one staff member present today has current EMSA approved Pediatric/Child CPR and First Aid.

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
To order forms please visit our website at www.ccld.ca.gov

No deficiencies observed in the areas inspected during today's visit.

Licensing report was reviewed and discussed with director.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amanda BlesiTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1