233009750-5-1-2025-01-CC-RMAL-DG9V7M-20250501161122

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 233009750
Report Date: 05/01/2025
Date Signed: 05/01/2025 04:11:44 PM

Document Has Been Signed on 05/01/2025 04:11 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	ROGINAS ROMPERS		FACILITY NUMBER:	233009750
ADMINISTRATOR/ DIRECTOR:	SUBLET, AMBER		FACILITY TYPE:	850
ADDRESS:	1901 WILDWOOD ROAD		TELEPHONE:	(707) 621-4186
CITY:	UKIAH	STATE: CA	ZIP CODE:	95482
CAPACITY: 20	TOTAL ENROLLED CHILDREN: 18	CENSUS: 14	DATE:	05/01/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:05 PM
MET WITH:	Amber Sublet		TIME VISIT/ INSPECTION COMPLETED:	04:16 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 required annual inspection of the facility was conducted by Licensing Program Analyst (LPA) Robert Maciel, who met with Director Amber Sublet. The facility file was reviewed prior to this inspection. 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. 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. The facility’s operating hours are from 8:00 AM - 4:30 PM Monday-Thursday. The facility was toured inside and outside and the floor and yard plans submitted by the licensee were verified. The sign-in/sign-out records were reviewed. Items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be out of reach, inaccessible to children. Director stated poisons are not stored in the facility and none were observed by the LPA. 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 indoors and outdoors by use of individual water bottles. The children's bathroom is in safe and sanitary condition. Children's lunch and snack are brought from home. Garbage cans containing solid waste have tight fitting lids. LPA observed a working carbon monoxide detector, smoke alarm, and fire extinguisher rated at least 2A10BC in the facility. Last emergency drill was conducted on 4/29/25. Continued on LIC809-C

Melchisedeck Augustin	TELEPHONE: (707) 588-5036
Robert Maciel	TELEPHONE: (707) 588-5026
	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROGINAS ROMPERS	FACILITY NUMBER: 233009750
	VISIT DATE: 05/01/2025

NARRATIVE

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The playground equipment and surface areas are in safe condition. There is rubber mat cushioning underneath climbing structures and/or play equipment to absorb falls. There are no bodies of water observed on the site. Director stated no weapons are stored on site, and none were observed. During today's inspection, staffing ratios were being met, and 14 children were supervised by 2 staff. One staff member present during the inspection possessed a current CPR and First Aid certification which expires in January 2027. Five children’s records were reviewed at 3:10 PM which revealed that an Epi-pen for child 6 (C6) had expired in June 2024. Two staff records were reviewed at 2:05 PM which contained all records as required.

The following violation of the California Code of Regulations, Title 22; Division 12, were observed during today’s visit. See LIC 809-D. Appeal Rights were provided. Exit interview conducted and report was reviewed with the Director, Amber Sublet. A notice of site visit was given and must remain posted for 30 days. An annual continuation visit will be conducted on a later date.

SUPERVISOR'S NAME: Melchisedeck Augustin	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2025 04:11 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROGINAS ROMPERS	FACILITY NUMBER: 233009750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

101226(e)(2)

Health-Related Services

(2) All prescription and nonprescription medications shall be maintained with the child's name and shall be dated. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, an Epi-pen for child 6 (C6) had expired in June 2024 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/15/2025
	Plan of Correction
1 2 3 4	Licensee stated she would return the expired epi-pen to the parents of C6 during pick-up on 5/1/25 and would utilize the LIC622 Centrally Stored Medication and Destruction Record form to record medication for all enrolled children with medication and would send a picture of the complete form to LPA by email at robert.maciel@dss.ca.gov.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Melchisedeck Augustin	TELEPHONE: (707) 588-5036
Robert Maciel	TELEPHONE: (707) 588-5026
	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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