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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483001837
Report Date: 01/14/2022
Date Signed: 01/14/2022 10:25:09 AM

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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
483001837
ADMINISTRATOR:CANARIOS, ROSEFACILITY TYPE:
830
ADDRESS:35 ROTARY WAYTELEPHONE:
(707) 557-3007
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:36CENSUS: 7DATE:
01/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:36 AM
MET WITH:Elizabeth Roberson - Assistant Center DirectorTIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced Case Management visit and met with the Assistant Center Director, Elizabeth Roberson (AD) for the purpose of addressing concerns pertaining to staff (S1 & S2) working at the facility without an approved criminal record clearance. LPA interviewed S1 on 01/05/22, CD on 01/13/22, and AD on 01/14/22. S1 confirmed she was hired in September 2021, and S1’s responsibilities consisted of providing care and supervision to the children in care. CD’s statement revealed S1 and S2 were hired several months ago and both staff worked more than five days at the facility on either a part time, full time; or on call basis. The statement that AD provided claimed AD saw S1 worked at the facility at least five days, while, S2 worked three days. A review of S1 and S2's time sheets revealed S1 and S2 worked more than five days at the facility, and on 01/14/22, LPA reviewed staff criminal record clearance status on the Department records, and according to the records, S1 and S2 did not obtain an approved criminal record clearance or exemption, and as such; a $1000 Civil Penalty is being assessed for violation of California Code of Regulations (CCR) 101170(e)(1).

Facility representative 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. LPA provided CD with a copy of CCR 101170.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the facility representative. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2022
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 483001837
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2022
Section Cited

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department or
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This required is not met as evidenced by: Based on Department records, staff time sheets and statements provided by S1, CD and AD which corroborated S1 & S2 worked at the facility without a criminal record or exemption clearance; and a $1000 Civil Penalty was assessed, as this posed an immediate health, safety, and personal rights risk to the children in care.
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AD also stated the facility would produce a written statement which would detail how the facility intends to comply with CCR 101170.

email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099

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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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 01/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/14/2022
LIC809 (FAS) - (06/04)
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