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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009270
Report Date: 05/24/2023
Date Signed: 05/24/2023 03:21:28 PM


Document Has Been Signed on 05/24/2023 03:21 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:PUBLIC SAFETY ACADEMY STATE PRESCHOOLFACILITY NUMBER:
483009270
ADMINISTRATOR:ANNA MANSKERFACILITY TYPE:
850
ADDRESS:230 ATLANTIC AVENUETELEPHONE:
(707) 438-3684
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:24CENSUS: 17DATE:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Anna Mansker TIME COMPLETED:
03:25 PM
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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 05/24/2023 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 Title 5 funded program.

The facility’s operating hours are 08:15AM- 03:00PM, Monday – Friday, It is a half day program with AM/PM class. 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. Poisons are are not stored on the premises. 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 fountains. The children’s bathrooms were in safe and sanitary condition. A current menu was posted inside the classroom on the parent board. 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 17 children were being supervised by five teachers/aides. 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: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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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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: PUBLIC SAFETY ACADEMY STATE PRESCHOOL
FACILITY NUMBER: 483009270
VISIT DATE: 05/24/2023
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The facility was operating within the licensed capacity. At least one staff member present during the visit (S1) possessed current CPR and First Aid certifications. Five children’s records were reviewed at 12:20PM, and contained identification forms with authorized representative information, as well as medical assessments. Five staff records were reviewed at 11:00AM, and one staff ( S1) contained health screening forms, four staff had incomplete health screening forms, deficiency was issued. The facility was not able to produce staff qualifications for three staff members, deficiency was issued. 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 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: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/24/2023 03:21 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: PUBLIC SAFETY ACADEMY STATE PRESCHOOL
FACILITY NUMBER: 483009270

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(2)
Personnel Requirements
(2) Each person specified in (g) above shall have a health-screening report signed by the person performing the screening. This report shall indicate the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, Five staff records were reviewed, four staff ( S2-S4) had incomplete LIC 503 on file, none were signed by physician and they were missing the TB test section. The licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2023
Plan of Correction
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Center Director reported they will reach out to HR and request support to receive copies of the Health screening report and email LPA Hernandez Torres when the reports have been received then place them in the personnel files.
Type B
Section Cited
CCR
101217(d)
Personnel Records
(d) All personnel records shall be maintained at the child care center and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, Center Director was not able to get a hold of HR to request the staff qualifications for three out of five staff. The licensee did not comply with the section cited above which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/07/2023
Plan of Correction
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Prior to LPA Hernandez Torres leaving the facility Center Director received email with the Staff qualifications for the three staff members who were missing the qualifications in their files. The center Director agreed to bring the regulation to HR to collaborate and ensure staff have completed Personnel files.
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: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3