490108547-1-22-2020-01-CC-ASTR-BL3TF4-20200122134055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490108547
Report Date: 01/22/2020
Date Signed: 01/22/2020 01:41:01 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:	WOODSIDE WEST SCHOOL-AFTER SCHOOL PROGRAM		FACILITY NUMBER:	490108547
ADMINISTRATOR:	DUMBADGE, DIANA		FACILITY TYPE:	840
ADDRESS:	2577 GUERNEVILLE ROAD		TELEPHONE:	(707) 528-6666
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95401
CAPACITY:	30	CENSUS: 2	DATE:	01/22/2020
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Diana Dumbadge		TIME COMPLETED:	01:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An annual random inspection was made to the facility by Licensing Program Analyst (LPA) Amy Strother. The School Age program is an after-school program and part of a combination center with Woodside West School. 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. LPA met with Director, Diana Dumbadse, who provided a current roster of children. Facility hours are 6:45am-8:00am and 2:00-6:00pm, Monday through Friday. LPA inspected the facility indoors and outdoors. Director stated that there are no bodies of water in the facility and none were observed by LPA. Director stated that there are no firearms in the facility and none were observed by LPA. The items which could pose a danger to children (detergents, cleaning compounds, and medications) were inaccessible to children. There was clean drinking water available to children both indoors and outdoors. Director stated there are no poisons, and none were observed by LPA. There is a functional smoke detector, and there is a functional carbon monoxide detector in the facility. The school age children use the bathrooms out in the main office area of the school, which were in clean, sanitary, and functional order. All floors were clean and sanitary. All kitchen food preparation and storage areas were observed to be clean and free of litter and rubbish and free of rodents and other vermin. All storage containers for solid waste, have tight-fitting covers. Food was observed to be kept at a safe temperature. The facility was free of flies, other insects, and rodents. LPA observed a fully charged fire extinguisher, rated at least 2A10BC. A fire drill was conducted on 01/07/2020. A current menu was posted. There was at least one person with CPR/First Aid certification, which expires on 8/2020. LPA examined 4 children's files, which contained Parents' Rights and other required forms. LPA examined one staff file, which contained transcripts, immunization records, and other required forms. This facility is providing Incidental Medical Services (IMS). The Department’s IMS policy was discussed with the Director. Continue on LIC809-C

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2020

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: WOODSIDE WEST SCHOOL-AFTER SCHOOL PROGRAM	FACILITY NUMBER: 490108547
	VISIT DATE: 01/22/2020

NARRATIVE

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The Director stated that she will revise the facilities Medication at School statement to add the information required for an IMS Plan of Operation and submit it to LPA Strother for review. 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: 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.

There were no Title 22 deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2020

LIC809 (FAS) - (06/04)

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