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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490105368
Report Date: 08/04/2023
Date Signed: 08/04/2023 11:46:25 AM


Document Has Been Signed on 08/04/2023 11:46 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:LITTLE SHEPHERD LUTHERAN PRESCHOOLFACILITY NUMBER:
490105368
ADMINISTRATOR:NAUGLE, KIMBERLYFACILITY TYPE:
850
ADDRESS:220 STANLEY STREETTELEPHONE:
(707) 769-0462
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:70CENSUS: 0DATE:
08/04/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Kimberly NaugleTIME COMPLETED:
11:50 AM
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LPA Robert Maciel met with Director Kimberly Naugle (D1) on 8/4/23 to discuss facility compliance for when the facility starts day care on 8/16. LPA reviewed with D1 which documents are required to be posted in a publicly accessible area, required documents to be reviewed during inspection, personnel and children's records to be reviewed during inspection, incidental medical services and action plans, and the locations of carbon monoxide detectors, smoke alarms, and fire extinguishers.

The building's fire system is wired with pull alarms in every room on-limits. There were fire extinguishers in the main hall and the kitchen. Medication is stored in the staff office.

The facility uses bottled water only for drinking and food preparation as of August 2020. D1 states that they started using bottles as a reaction to the pandemic. Faucets in the facility are only used for washing hands and are labeled as such. Parent handbook given to parents before child admission as of June 2021, maps out all facility faucets in use and notes that all faucets are not used for drinking or food prep. Facility has not conducted a test for lead but intends to continue to use bottled water only and so the director will write a waiver and send to LPA by email.

A notice of site visit was given and must remain posted for 30 days. Report was reviewed with Director Kimberly Naugle.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2023
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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