483009264-11-16-2023-01-CC-RMAL-CXMSTV-20231116131010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 483009264
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:10:23 PM

Document Has Been Signed on 11/16/2023 01:10 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:	BETHANY LUTHERAN PRESCHOOL		FACILITY NUMBER:	483009264
ADMINISTRATOR:	HART, NATALIE		FACILITY TYPE:	850
ADDRESS:	1011 ULATIS DRIVE		TELEPHONE:	(707) 451-6683
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	48	CENSUS: 9	DATE:	11/16/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Natalie Hart		TIME COMPLETED:	01:16 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 Analysts (LPAs) Robert Maciel and Melchisedeck Augustin, who met with Director Natalie Hart. 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 6:30 AM - 6:00 PM Monday-Friday. The facility was toured inside and outside and the floor and yard plan 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 on site and none were observed by 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 bathrooms are in safe and sanitary condition. The facility does not provide food to children. Center director confirmed that all children's parents provide lunch and two snacks in lieu of the facility. Garbage cans containing solid waste have tight fitting lids. LPAs observed a working carbon monoxide detector, smoke alarm, and fire extinguisher rated at least 2A10BC in the facility. Last emergency drill was conducted on 10/19/23. 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: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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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Document Has Been Signed on 11/16/2023 01:10 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: BETHANY LUTHERAN PRESCHOOL	FACILITY NUMBER: 483009264
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101216.1(b)(1)

Teacher Qualifications and Duties

(b) Prior to employment, a teacher shall meet the requirements of (b)(1) or (b)(2) below: (1) A teacher shall have completed, with passing grades, at least six postsecondary semester or equivalent quarter units of the education requirement specified in (c)(1) below; or shall have obtained a Child Development Assistant Permit issued by the California Commission on Teacher Credentialing. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, S1 did not possess evidence to confirm her qualification as fully qualified teacher which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2023
	Plan of Correction
1 2 3 4	Director stated that she would obtain the complete transcripts and send them to LPA Maciel by email. robert.maciel@dss.ca.gov

Type B

Section Cited

CCR

101220(a)

Child's Medical Assessments

(a) Prior to, or within 30 calendar days following the enrollment of a child, the licensee shall obtain a written medical assessment of the child. This medical assessment enables the licensee to assess whether the center can provide necessary health-related services to the child. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, C1, C2, C4, and C5 did not possess a complete written medical assessment which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2023
	Plan of Correction
1 2 3 4	Director stated that she would obtain the completed records and send them to LPA Maciel by email. 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: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/16/2023 01:10 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: BETHANY LUTHERAN PRESCHOOL	FACILITY NUMBER: 483009264
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101221(a)

Child's Records

(a) The licensee shall ensure that a separate, complete and current record for each child is maintained in the child care center. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, C1 - C5 did not possess admissions agreements, and C3 did not possess a complete immunization record which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/07/2023
	Plan of Correction
1 2 3 4	Director stated that she would obtain the immunization record for C3 and admission agreements for C1-C5 and send them to LPA Maciel by email. robert.maciel@dss.ca.gov

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: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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: BETHANY LUTHERAN PRESCHOOL	FACILITY NUMBER: 483009264
	VISIT DATE: 11/16/2023

NARRATIVE

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The playground equipment and surface areas are in safe condition. There is wood chip cushioning underneath climbing structures and/or play equipment to absorb falls. Two of the climbing structures in the outdoor playground have a recommended age usage of 5-12 years of age. Director stated that she was aware of the age restriction and does not allow children to play on either structure while children are present in the playground. Additionally, the facility has a waiver for shared usage of the playground with the Transitional Kindergarten class at the facility. Usage of the playground is staggered so that neither group is using the playground at the same time. There are no bodies of water observed on the site. Director stated no weapons are stored on site, and none were observed. During today's inspection, staffing ratios were being met, and 9 children were supervised by 1 staff. The facility was operating within the licensed capacity and ratio requirements. At least one staff member present during the inspection possessed current CPR and First Aid certifications, which expire in 11/12/2024. Five children’s records were reviewed at 10:44 AM which revealed that child 1 - child 5 (C1-C5) did not possess admission agreements, LIC 701, LIC 702, and an immunization record. Three staff records were reviewed at 9:48 AM which revealed that staff 1 (S1) was did not possess a complete LIC9095 and that records for S1 - S3 do not state date of employment.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

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: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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: BETHANY LUTHERAN PRESCHOOL	FACILITY NUMBER: 483009264
	VISIT DATE: 11/16/2023

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 violation of the California Code of Regulation, Title 22, Division 12, was cited: see LIC809-D. Appeal Rights were provided. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director, Natalie Hart.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert Maciel	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC809 (FAS) - (06/04)

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