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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009962
Report Date: 11/17/2021
Date Signed: 11/17/2021 02:47:33 PM

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:VCUSD-LOMA VISTA CDC P/SFACILITY NUMBER:
483009962
ADMINISTRATOR:RUND, JENNIFERFACILITY TYPE:
850
ADDRESS:146 RAINIER STREETTELEPHONE:
(707) 556-8550
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:48CENSUS: 2DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Elizabeth Santos and Jennifer RundTIME COMPLETED:
02:50 PM
NARRATIVE
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A Required inspection was made to the facility by Licensing Program Analyst (LPA), Melchisedeck Augustin. The facility file was reviewed prior to this visit. The Director stated the school district ensured that district staff obtained criminal record or exemptions prior to working at the facility. This program is operated in classrooms #17 and 27 by a public agency and is a Title 5 funded program.

The facility’s operating hours are 7:00am to 5:00pm, Mon-Fri. At 9:45am, LPA observed current menus posted near the front entrance, however; the menus did not include food serving size(s). The Center Director stated staff records were stored off site at the district office. The 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. 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, Jennifer Rund.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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: VCUSD-LOMA VISTA CDC P/S
FACILITY NUMBER: 483009962
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101227(a)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. During today's inspection, LPA observed the posted menus did not indicate the food serving size(s) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/24/2021
Plan of Correction
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The Center Director stated she would amend the menu to include the serving size. The Director would submit the updated copy of the breakfast, lunch and snack menus to the Department by 11/24/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2021
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: VCUSD-LOMA VISTA CDC P/S
FACILITY NUMBER: 483009962
VISIT DATE: 11/17/2021
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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.

California Code of Regulations, Title 22 deficiency was cited on LIC 809-D. Appeal Rights were provided.

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

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC809 (FAS) - (06/04)
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