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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490100648
Report Date: 11/15/2019
Date Signed: 11/15/2019 12:37:10 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:PRESBYTERIAN PRE-SCHOOLFACILITY NUMBER:
490100648
ADMINISTRATOR:LOUPY, LUCYFACILITY TYPE:
850
ADDRESS:1550 PACIFIC AVENUETELEPHONE:
(707) 542-7396
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:30CENSUS: 22DATE:
11/15/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:48 AM
MET WITH:Amby TakekawaTIME COMPLETED:
12:55 PM
NARRATIVE
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A annual random inspection was made to the facility by Licensing Program Analyst (LPA), Amy Strother. The facility file was reviewed prior to this visit. 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.

This facility offers a morning session 8:45am-11:45am Monday-Friday and an afternoon session 1:00pm-4:00pm Monday-Thursday. 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 that no poisons are stored on the premises and none were observed during today's inspection. The toys, floors, tables and other equipment and surfaces are clean, toxic free, safe and in good condition. There is drinking water available to children both indoors via disposable cups and a sink and outdoors via a drinking fountain. The children's bathrooms are in safe and sanitary condition. Food prep areas are clean. Food is properly stored and refrigerated as needed. There was no contaminated food observed. Garbage cans containing solid waste have tight fitting lids. The LPA observed a working carbon monoxide detector in the facility. The playground was free of hazards. The playground equipment and surface areas were in safe condition. There is wood chip or rubber mat 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 22 children were being supervised by 4 teachers/aides. The facility was operating within the licensed capacity. At least one staff member present during the visit, the director, possessed current CPR and First Aid certifications. The sign-in/sign-out procedure was reviewed and in compliance. Five children’s records were reviewed at 10:30am, and contained signed admission agreements.
Continue on LIC809-C
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: PRESBYTERIAN PRE-SCHOOL
FACILITY NUMBER: 490100648
VISIT DATE: 11/15/2019
NARRATIVE
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Two staff (S1 and S2) records were reviewed at 11:23am and contained documentation of education and training as required. Staff 1 (S1) and Staff 2 (S2) did not have a Mandated Reporter Training certificate on file. LPA requested the Mandated Reporter Training certificate for S1 and S2 from the director. The director stated that she does not have a Mandated Reporter Training certificate for S1 or S2 available and that they completed the training for School Personnel, but does not have a record available. This facility is providing Incidental Medical Services (IMS). The Department’s IMS policy was discussed with the Director. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. The director stated that she does not have Plan of Operation for providing IMS at this time, but will work on developing one and submit it to CCLD. 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 brochure, 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.

The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. Appeal Rights were provided.

An exit interview was conducted and Plans of corrections were reviewed and developed with the Licensee. Appeal Rights were provided and discussed with, Amby Takekawa whose signature on this form confirm receipt of these documents.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: PRESBYTERIAN PRE-SCHOOL
FACILITY NUMBER: 490100648
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2019
Section Cited

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Mandated Reporter Training. On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training…
This requirement was not met as evidenced by:
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Based on record review and interview, the licensee failed to ensure that Staff 1(S1) and Staff 2 (S2) completed the mandated reporter training. This poses a potential health and safety risk to children in care.
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Email: amy.strother@dss.ca.gov
Fax: 707-588-5099

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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: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3