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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233009679
Report Date: 04/19/2023
Date Signed: 04/19/2023 03:35:45 PM


Document Has Been Signed on 04/19/2023 03:35 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:IMAGINATION STATION-INFANT CENTERFACILITY NUMBER:
233009679
ADMINISTRATOR:RODRIGUEZ, SAPRINAFACILITY TYPE:
830
ADDRESS:262 EAST COMERCIAL STREETTELEPHONE:
(707) 459-6543
CITY:WILLITSSTATE: CAZIP CODE:
95490
CAPACITY:30CENSUS: 26DATE:
04/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Saprina RodriguezTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA), Amy Strother conducted a Case Management inspection at the facility after receiving an Unusual Incident/Injury Report (UIR) on 04/07/23. LPA met with Licensee/Center Director, Saprina Rodriguez (L1). The UIR stated that a child, Child 1 (C1) broke out in a rash while in care on 04/04/23 and that on 04/07/23 the facility was notified that C1 had Chickenpox (Varicella). The UIR stated that C1’s immunization records were reviewed and C1 did not have a record of a vaccination for Varicella on record. C1 is beyond the age that children are required to receive the Varicella vaccination to be present at a Child Care Center. During a telephone interview with L1 on 04/10/23 at 11:58am, L1 stated that C1's birth date is 07/09/21, C1 was first enrolled on 07/11/22 but left the program on 08/03/22 to later re-enrolled. L1 stated that C1 was re-enrolled on 03/08/23 and is still currently enrolled. L1 stated that C1 did not have the Varicella vaccine and was admitted into the facility on 03/08/23, a time when she was over due for the Varicella vaccine.

Based on interview with L1 and record review during today’s inspection, the Licensee admitted C1 into the facility on 03/08/23 without all of the required immunizations.

The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. Appeal Rights were provided.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Saprina Rodriguez.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
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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Document Has Been Signed on 04/19/2023 03:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: IMAGINATION STATION-INFANT CENTER
FACILITY NUMBER: 233009679

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/03/2023
Section Cited

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(a) Prior to admission to a child care center, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, commencing with Section 6000.

This requirement was not met as evidenced by:
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L1 will review all immunization records for children enrolled, complete the CDPH286 form and certify that all children have the required immunizations or the child(ren) will be excluded until L1 has received proof of immunization(s) as required, submitting form LIC9098 to LPA Strother at amy.strother@dss.ca.gov by 05/03/23 as proof of correction.
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Based on record review and interview with L1, C1 was not immunized against Varicella as required prior to admission on 03/08/23. The licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
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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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2023
LIC809 (FAS) - (06/04)
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