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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483006244
Report Date: 12/08/2022
Date Signed: 12/08/2022 03:50:17 PM


Document Has Been Signed on 12/08/2022 03:50 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:FAIRFIELD-SUISUN CHILD DEVELOPMENT CENTERFACILITY NUMBER:
483006244
ADMINISTRATOR:ANNA MANSKARFACILITY TYPE:
850
ADDRESS:830 FIRST STREETTELEPHONE:
(707) 438-3684
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:60CENSUS: 15DATE:
12/08/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Anna Mansker TIME COMPLETED:
04:00 PM
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A required inspection was completed today by Licensing Program Analysts (LPA) Elpidia Hernandez Torres. The entire inspection was not completed on 12/06/2022, as facility did not furnish staff records nor children's records and a continuation visit to review personnel records was required.

On 12/08/2022, at Six children’s records were reviewed at 12:53PM, and contained identification forms with authorized representative information, as well as medical assessments. All files had required emergency information and Blue CDPH 286 completed. The sign in/out procedure was reviewed and in compliance. Six staff records were reviewed at 02:20PM, they contained all required Licensing forms and staff qualifications. All six staff had incomplete health screening forms they were missing a physicians signature, an advisory note was issued.

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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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: http://www.ada.gov/childqanda.htm

Continued on 809-C

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022
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: FAIRFIELD-SUISUN CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 483006244
VISIT DATE: 12/08/2022
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A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Center Director Anna Mansker.

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 LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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