233009750-4-9-2024-01-CC-RMAL-D46U6S-20240409151850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 233009750
Report Date: 04/09/2024
Date Signed: 04/09/2024 03:19:09 PM

Document Has Been Signed on 04/09/2024 03:19 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	ROGINAS ROMPERS		FACILITY NUMBER:	233009750
ADMINISTRATOR:	SUBLET, AMBER		FACILITY TYPE:	850
ADDRESS:	1901 WILDWOOD ROAD		TELEPHONE:	(707) 621-4186
CITY:	UKIAH	STATE: CA	ZIP CODE:	95482
CAPACITY:	20	CENSUS: 13	DATE:	04/09/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Amber Sublet		TIME COMPLETED:	03:31 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 8/29/23. Continued on LIC809-C

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROGINAS ROMPERS	FACILITY NUMBER: 233009750
	VISIT DATE: 04/09/2024

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 record review, LPA observed that the licensee did not fully complete the LIC 9275 External Water Sampler Self-Certification Form, the LIC 9276 Child Care Center Sampling Checklist Form, or the LIC 999 Facility Sketch fully labeled with the locations of all water outlets, including outlets that were not sampled. LPA observed that the facility's first aid kit did not contain sterile first-aid dressing. During today's inspection, staffing ratios were being met, and 13 children were supervised by 2 staff. The facility was operating within the licensed capacity and ratio requirements. One staff member present during the inspection possessed a current CPR and First Aid certification, however, the certification was not issued by the American Red Cross, the American Heart Association, or by a training program that has been approved by the Emergency Medical Services Authority. Five children’s records were reviewed at 10:29 AM which revealed that child 1 (C1) and child 5 (C5) did not possess complete admission agreements and child 1-5 (C1-C5) did not possess complete physician's reports. Two staff records were reviewed at 10:53 AM which revealed that staff 1 (S1) and staff 2 (S2) did not possess current Mandated Reporter Training Certificates, S2 did not possess a complete LIC 501 Personnel Record, record of a health screening, or proof of immunization against measles, pertussis, and influenza.

LPA referred licensee to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Continued on LIC 809C

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

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

FACILITY NAME: ROGINAS ROMPERS	FACILITY NUMBER: 233009750
	VISIT DATE: 04/09/2024

NARRATIVE

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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

The following violations 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

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/09/2024 03:19 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROGINAS ROMPERS	FACILITY NUMBER: 233009750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.16(a)(1)

Lead Testing

(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not fully complete the LIC 9275 External Water Sampler Self-Certification Form, the LIC 9276 Child Care Center Sampling Checklist Form, or the LIC 999 Facility Sketch which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2024
	Plan of Correction
1 2 3 4	Licensee stated she would complete lead testing in accordance to PIN 21-21.1-CCP and send the results to LPA by email at robert.maciel@dss.ca.gov.

Type B

Section Cited

CCR

101174(d)

Disaster and Mass Casualty Plan

(d) Disaster drills shall be conducted at least every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the last disaster drill conducted by the facility was conducted more than 6 months ago which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2024
	Plan of Correction
1 2 3 4	Licensee says she will conduct a diaster drill on 4/10/24 and send a picture of the disaster log to LPA by email at robert.maciel@dss.ca.gov.

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/09/2024 03:19 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROGINAS ROMPERS	FACILITY NUMBER: 233009750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101226(d)(2)

Health-Related Services

(d) The licensee shall maintain the following first-aid supplies in a location accessible to staff but inaccessible to children: (2) Sterile first-aid dressings. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the facility's first aid kit did not contain sterile first-aid dressing which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2024
	Plan of Correction
1 2 3 4	Licensee stated that she would purchase sterile first aid dressing and send a picture of the complete first aid kit to LPA by email at robert.maciel@dss.ca.gov.

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, staff 1 (S1) and staff 2 (S2) did not possess current Mandated Reporter Training Certificates which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2024
	Plan of Correction
1 2 3 4	Licensee stated she would ensure S1 and S2 obtain current Mandated Reporter Training Certificates and send copies to LPA by email at robert.maciel@dss.ca.gov

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/09/2024 03:19 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROGINAS ROMPERS	FACILITY NUMBER: 233009750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.7995(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review,staff 2 (S2) did not possess proof of immunization against influenza, pertussis, and measles which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2024
	Plan of Correction
1 2 3 4	Licensee stated she would ensure she receives proof of S2's immunizations and send a copy to LPA by email at robert.maciel@dss.ca.gov

Type B

Section Cited

CCR

101216(g)(1)

Personnel Requirements

(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review,staff 2 (S2) did not possess a complete LIC503 Health Screening form which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2024
	Plan of Correction
1 2 3 4	Licensee stated she would ensure she obtains S2's LIC503 Health Screening form and send a copy to LPA by email at robert.maciel@dss.ca.gov

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/23/2024 01:56 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 04/17/2024 09:04 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ROGINAS ROMPERS	FACILITY NUMBER: 233009750
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101217(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review,staff 2 (S2) did not possess a complete LIC501 Personnel Record form which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2024
	Plan of Correction
1 2 3 4	Licensee stated she would obtains S2's LIC501 Personnel Record form and send a copy to LPA by email at robert.maciel@dss.ca.gov

Type B

Section Cited

CCR

101221(b)(6)

Child's Records

(b) Each record shall contain information including, but not limited to, the following: (6) A signed copy of the admission agreement specified in Section 101219. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, child 1 (C1) and child 5 (C5) did not possess complete admission agreements which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2024
	Plan of Correction
1 2 3 4	Licensee stated she would obtain complete admission agreements and send a copy to LPA by email at robert.maciel@dss.ca.gov.

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: Jordan Monath	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Alexis Hollon	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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