173002941-5-6-2019-01-CC-CARD-BBWUAZ-20190506152535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 173002941
Report Date: 05/06/2019
Date Signed: 05/06/2019 03:25:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	KELSEYVILLE MIGRANT HEAD START-INFANT		FACILITY NUMBER:	173002941
ADMINISTRATOR:	FLORES, PATRICIA		FACILITY TYPE:	830
ADDRESS:	5081 A KONOCTI ROAD		TELEPHONE:	(707) 279-1022
CITY:	KELSEYVILLE	STATE: CA	ZIP CODE:	95451
CAPACITY:	32	CENSUS: 10	DATE:	05/06/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Patricia Flores		TIME COMPLETED:	03:45 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	A random annual inspection was made to the facility by Licensing Program Analyst (LPA) Chris Arnhold. The facility file was reviewed prior to this visit. A review of the personnel report on file indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. This is an E Center, Head Start program. There is a toddler component associated with this infant license. This program operates April through October. Operating hours are Monday - Friday, 5:30am- 5:30pm. The facility was toured inside and outside and the floor and yard plan submitted were verified. The items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children. Director stated there are no Poisons at facility. The facility was free of flies, insects and rodents. The toys, floors, desks and other equipment and surfaces are clean, toxic free, safe and in good condition. There is uncontaminated drinking water available to children both indoors and outdoors. The children's bathrooms are in safe and sanitary condition. A current menu was posted. Food prep areas are clean. Food is properly stored and refrigerated as needed. Garbage cans containing solid waste have tight fitting lids. The playground was free of hazards. The playground equipment and surface areas are in safe condition. There is cushioning underneath climbing structures and/or play equipment to absorb falls. There were no bodies of water observed. The Director stated no weapons are stored on site and none were observed. During today's inspection, staffing ratios were being met and 10 children were being supervised by 6 teachers. The facility was operating within the licensed capacity. At least one staff member present during the visit possessed current CPR and First Aid certifications. Six children’s records were reviewed at 1:45PM, and contained identification forms with authorized representative information. Three staff records were reviewed at 2:15PM, and contained documentation of education and training, as required. This facility is not providing Incidental Medical Services (IMS). Continued on LIC809-C.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5056
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2019

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: KELSEYVILLE MIGRANT HEAD START-INFANT	FACILITY NUMBER: 173002941
	VISIT DATE: 05/06/2019

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
26
27
28
29
30
31
32

The Department’s Incidental Medical Services (IMS) policy was discussed with the Director. 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: www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices and The Effects of Lead Exposure brochures, were reviewed and discussed with the Director. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5056
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2019

LIC809 (FAS) - (06/04)

Page: 2 of 2