Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313620603
Report Date: 07/22/2015 12:00:00 AM
Date Signed 07/22/2015 01:58:23 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:CLUB ROCKLIN CDI - RUHKALA (SA)FACILITY NUMBER:
313620603
ADMINISTRATOR:RIOS, ROSIEFACILITY TYPE:
840
ADDRESS:6530 TURNSTONE WAYTELEPHONE:
(916) 632-6560
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:60CENSUS: 0DATE:
07/22/2015
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rosie RiosTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPAs) Gina Jones and Katrina Owens are conducting a site visit for the purpose of a pre licensing evaluation of the school age license. Licensing met with applicant representative: Rosie Rios. Applicant is requesting a school age license with a maximum of 60 school age children. The program operates Monday - Friday from 7:00 am - 6:00 pm year round. The facility has a copy of the following documents posted in a conspicuous area: parent's rights, personal rights, menus, emergency disaster plan, earthquake preparedness checklist and car seat law.
INDOOR ACTIVITY SPACE:
The school -age program will be using portable room B on the Ruhkala Elementary School campus. The room is equipped with child size furnishings, including toys and learning equipment. There are individual hooks for storing children's personal belongings. The facility has an on-site kitchen where food preparation will be done. Food items will be stored in the kitchen with a refrigerator and freezer used for the cold items. The facility will be serving breakfast, lunch and a snack. Licensing observed a first aid kit, water will be available to children through a water fountain in the facility. Medications will be stored in the office and proper storage and usage will be maintained.
According to Title 22, Division 12, Sections 101538.2(c) & 101538.3(c), the school-age program is exempt from the indoor and outdoor square footage as well as the restroom requirements. From 7:00-7:55 am and 3:10- 6:00 pm M-F school age children may use the preschool bathrooms. A waiver request has been submitted for review.

REPORT CONTINUED ON THE FOLLOWING PAGE.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Gina JonesTELEPHONE: (916) 263-6279
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2015
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: CLUB ROCKLIN CDI - RUHKALA (SA)
FACILITY NUMBER: 313620603
VISIT DATE: 07/22/2015
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There is a separate staff bathroom. The isolation area for ill children will be located in the office area of the classroom. The facility will not be transporting school age children. There is a sign-in sign out log which will be located near the front door. Children and staff records will be located in the office area.

OUTDOOR ACTIVITY SPACE:
The outdoor play area is fenced with a minimum of 4' foot fencing. The play areas include black top and one play structure with bark cushioning. The playground has shaded areas with outside water being provided by two drinking fountain and thermos and cups will also be provided. The square footage will accommodate the requested capacity of 60 school age children.


During todays visit the following was discussed:
1. Children's and staff records.
2. The importance of care and supervision and maintaining ratios.
3. The reporting of Unusual Incidents.
4. Insuring all staff have criminal record clearances and are associated.

Fire clearance was approved by City of Rocklin Fire Department.

After the final submission and review of the requested application documents, the facility will be issued a license.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Gina JonesTELEPHONE: (916) 263-6279
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2015
LIC809 (FAS) - (06/04)
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