483001191-4-22-2022-01-CC-MAUN-CDQVHJ-20220422162713

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483001191
Report Date: 04/22/2022
Date Signed: 04/22/2022 04:27:22 PM

Document Has Been Signed on 04/22/2022 04:27 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:	HEAD START - VIRGINIA		FACILITY NUMBER:	483001191
ADMINISTRATOR:	L.SMITH,J.EDWARDS,G.GARROT		FACILITY TYPE:	850
ADDRESS:	1328 VIRGINIA		TELEPHONE:	(707) 974-8756
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94590
CAPACITY:	37	CENSUS: 22	DATE:	04/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Rhonda Winston - Center Director		TIME COMPLETED:	04:45 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 Required-1 Year inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. 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. All personnel are fingerprinted and associated to the Head Start Menlo Center # 280111518. This program is operated by Child Start Inc. The Center Director was reminded that all adults 18 and over, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated. The facility’s operating hours are 7:30am - 4:00pm, Monday-Friday. The facility was toured inside and outside and the floor and yard plan submitted by the licensee 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. LPA did not observe any poison(s). The toys, floors, desks and other equipment and surfaces are clean, toxic free, safe and in good condition. There is drinking water available to children both indoors and outdoors. The Director stated that children utilized cups to obtain water from the faucet indoors and the children utilize cups to obtain water from a water pitcher outdoor. The children's bathrooms are in safe and sanitary condition. Food prep areas are clean. Food is properly stored and refrigerated as needed. There was no contaminated food observed. A Menu was posted in an area accessible for review by the child's authorized representative. The Daily Activities schedule, the Emergency Disaster Plan (LIC 610), and Parents’ Rights (PUB 393) were posted in classroom #1 and #2. Garbage cans containing solid waste have tight fitting lids. LPA observed a working carbon monoxide and hardwired smoke detectors, and a fully charged fire extinguisher rated at least 2A10BC. The playground was free of hazards. The playground equipment and surface areas were in safe condition. There is wood chips and foam cushioning underneath climbing structures and/or play equipment to absorb falls. (Continue to LIC 809-C)

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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

FACILITY NAME: HEAD START - VIRGINIA	FACILITY NUMBER: 483001191
	VISIT DATE: 04/22/2022

NARRATIVE

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There is a Gabezo for shade area. There were no bodies of water observed. The Center Director stated no weapons are stored on site and none were observed. The Center Director did not furnish a completed facility roster of the children in care. LPA issued a Technical Violation for this deficiency. During today's inspection, staffing ratios were being met, and 22 children were being supervised by four teachers and one aide.

Ten (C1-C10) children’s records were reviewed at 11:00am and contained signed admission agreements, as well as identification and emergency information, and completed parents’ rights forms. The facility was operating within the licensed capacity. CD possessed a current Pediatric CPR and First Aid certification which expire on 05/2023. The sign-in/sign-out procedure was reviewed and was in compliance. Six staff (CD, & S1-S5) records were reviewed at 1:08pm which revealed CD’s record did not contain LIC 9096, LIC 503, Preventive Health and Safety certificate, Record keeping Orientation certificate, and LIC 9052, and LIC 9108. Staff records also revealed S1-S5’s records were either missing LIC 9095, LIC 9052, 9108 or LIC 503. The facility conducted an emergency disaster drill within last six months and the last drill was conducted on 02/14/22 and 02/22/22.

This facility is providing Incidental Medical Services (IMS). The Department’s IMS policy was discussed with the Licensee/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 Licensee/Center Director. All licensing reports are public information and must be made available upon request for at least three years.

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 Center Director, Rhonda Winston. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/22/2022 04:27 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: HEAD START - VIRGINIA	FACILITY NUMBER: 483001191
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101217(a)

Personnel Records. Personnel records shall be maintained on the licensee, administrator, and each employee, and shall contain specified information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on six staff records reviewed at 1:08pm which revealed CD’s record did not contain LIC 9096, LIC 503, Preventive Health and Safety certificate, Record keeping Orientation certificate, and LIC 9052, and LIC 9108, and S1-S5’s records were either missing LIC 9095, LIC 9052, 9108 or LIC 503. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2022
	Plan of Correction
1 2 3 4	The Center Director stated she would submit evidence of the completion of each staff records. The Center Director stated she would submit her evidence to the Department by 05/02/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099

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.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck Augustin	TELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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