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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490100475
Report Date: 04/30/2019
Date Signed: 05/02/2019 08:39:17 AM

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:CROSS & CROWN LUTHERAN PRESCHOOLFACILITY NUMBER:
490100475
ADMINISTRATOR:MC CARTHY, MANDYFACILITY TYPE:
850
ADDRESS:5474 SNYDER LANETELEPHONE:
(707) 795-7863
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:70CENSUS: 11DATE:
04/30/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Mandy McCarthyTIME COMPLETED:
04:54 PM
NARRATIVE
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An annual random inspection was made to the facility by Licensing Program Analyst (LPA), Y. Yang. The facility file was reviewed prior to this inspection. A review of the personnel report on 04/30/19 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The facility’s operating hours are 07:00am-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. The director stated there are no poisons stored on the premises and none were observed. 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 in the classroom and outdoors on the playground in a water cooler. 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 wood chip cushioning underneath climbing structures and/or play equipment to absorb falls. There were no bodies of water observed. The director stated no weapons are stored on site and none were observed. During today's inspection, staffing ratios were being met and there were 11 children were being supervised by two teachers. 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. Seven children’s records were reviewed at 04:15pm and contained identification forms with authorized representative information, as well as medical assessments. Three staff records were reviewed at 03:53pm, and contained health screening forms. The sign in/out procedure was reviewed and in compliance.
Continued on LIC 809-C
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2019
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: CROSS & CROWN LUTHERAN PRESCHOOL
FACILITY NUMBER: 490100475
VISIT DATE: 04/30/2019
NARRATIVE
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This facility is not providing Incidental Medical Services (IMS) to children. The Department’s IMS policy was discussed with the Director. 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: www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices and The Effects of Lead Exposure brochures, were reviewed and discussed with the Director. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2019
LIC809 (FAS) - (06/04)
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