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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490100475
Report Date: 10/04/2024
Date Signed: 10/04/2024 02:04:00 PM


Document Has Been Signed on 10/04/2024 02:04 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: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: 14DATE:
10/04/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Mandy McCarthyTIME COMPLETED:
01:02 PM
NARRATIVE
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An annual required 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 10/03/24 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 representative 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.

The LPA met with the facility's center director, Mandy McCarthy. The facility’s operating hours are 08:00am-05:00pm, Monday – Friday. The facility was toured inside and outside and the floor and yard plan submitted by the licensee were verified. The toys, floors, desks and other equipment and surfaces were clean, free of toxins, safe and in good condition. The facility was free of flies, insects and rodents. There is drinking water available to children both indoors in the classrooms and outdoors on the playground. The children’s bathrooms were in sanitary condition. Food prep areas are clean. Food is properly stored and free of contamination. Garbage cans containing solid waste were in good repair and had tight fitting lids. The facility's play yard is fully fenced and free of hazards. The play structure on the main play yard has wood chip cushioning material underneath. The director stated no weapons or poisons are stored on site. There is at least one smoke and carbon monoxide detector on site. During today's inspection the facility was operating within the licensed capacity. At least one staff member present during the visit possessed current CPR and First Aid certifications. The sign in/out procedure was reviewed and was in compliance with regulations. The facility is using an electronic sign in/out system. Ten children’s records were reviewed and contained identification forms with authorized representative information, as well as medical assessments, immunization logs, and parent's rights notification. Five staff records were also reviewed during the inspection visit. 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: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024
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 10/04/2024 02:04 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: CROSS & CROWN LUTHERAN PRESCHOOL

FACILITY NUMBER: 490100475

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 10/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the LPA's file review, the licensee did not comply with the section cited above in 1596.8662(b)(1). The LPA observed that staff S1, S2, and S3's California Mandated Reporter Training certificates were exppired. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/01/2024
Plan of Correction
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The center director stated that she submit the updated CA Mandated Reporter Training renewal certificates to the Department by 11/01/24.
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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2024
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: CROSS & CROWN LUTHERAN PRESCHOOL
FACILITY NUMBER: 490100475
VISIT DATE: 10/04/2024
NARRATIVE
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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, Mandy McCarthy. The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. Appeal rights provided.

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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
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