483009264-10-11-2022-01-CC-EHTS-CK4UCQ-20221011152819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483009264
Report Date: 10/11/2022
Date Signed: 10/11/2022 03:28:31 PM

Document Has Been Signed on 10/11/2022 03:28 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:	BETHANY LUTHERAN PRESCHOOL		FACILITY NUMBER:	483009264
ADMINISTRATOR:	HART, NATALIE		FACILITY TYPE:	850
ADDRESS:	1011 ULTAIS DRIVE		TELEPHONE:	(707) 451-6683
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	48	CENSUS: 41	DATE:	10/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Center Director Natalie Hart		TIME COMPLETED:	03:40 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	An annual inspection was made to the facility by Licensing Program Analyst (LPA), Elpidia Hernandez Torres. The facility file was reviewed prior to this inspection. A review of the personnel report on 10/11/2022 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. This program is operated by a private entity. The facility’s operating hours are 06:30AM-06:00PM, 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. Center Director stated poisons are not stored on the premises. The regulation that poisons are locked with a key or combination lock was reviewed. The facility was free of flies, insects and rodents. The toys, floors, desks and other equipment and surfaces were clean, toxic free, safe and in good condition. There is uncontaminated drinking water available to children both indoors and outdoors through the use of water bottles which are filled up before each transition. The children’s bathrooms were in safe and sanitary condition. Food prep areas are clean. Food is properly stored and free of contamination. Garbage cans containing solid waste have tight fitting lids. The playground was free of hazards. The playground equipment and surface areas were in safe condition. There is bark cushioning underneath climbing structures and/or play equipment to absorb falls. There were no bodies of water observed. The center director stated no weapons are stored on site and none were observed. During today's inspection, staffing ratios were being met and there were 41 children were being supervised by five teachers and Center Director. The facility was operating within the licensed capacity. At least one staff member present during the visit (S2) possessed current CPR and First Aid certifications. 10 children’s records were reviewed at 12:44PM, and contained identification forms with authorized representative information. Four children C1.C2.C3, and C5 were missing medical assessments and advisory note was issued. All children were missing admission agreement printed and signed in their files. An advisory note was issued, Center director agreed to print out the admission agreements and specify who they belong to and place in the childrens' file. Continued on 809-C

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez Torres	TELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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: BETHANY LUTHERAN PRESCHOOL	FACILITY NUMBER: 483009264
	VISIT DATE: 10/11/2022

NARRATIVE

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Five staff records were reviewed at 11:17AM, and contained health screening forms. The sign in/out procedure was reviewed and in compliance.

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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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)/ (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

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 Natalie Hart.

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: Elpidia Hernandez Torres	TELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC809 (FAS) - (06/04)

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