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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108547
Report Date: 01/25/2023
Date Signed: 01/25/2023 05:06:21 PM


Document Has Been Signed on 01/25/2023 05:06 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:WOODSIDE WEST SCHOOL-AFTER SCHOOL PROGRAMFACILITY NUMBER:
490108547
ADMINISTRATOR:DUMBADGE, DIANAFACILITY TYPE:
840
ADDRESS:2577 GUERNEVILLE ROADTELEPHONE:
(707) 528-6666
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:30CENSUS: 7DATE:
01/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Diana DumbadseTIME COMPLETED:
05:25 PM
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A required one year inspection was made to the facility by Licensing Program Analyst (LPA), Amy Strother. LPA met with Facility Representative and Director, Diana Dumbadse (D1). The facility file was reviewed prior to this visit. A review of the personnel report on file indicates that all facility staff have received criminal record and child abuse index clearances or exemptions. D1 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.

This is a school-age license, part of a combination center with Woodside West School, serving preschool age children. The facility’s operating hours are 6:45 a.m. - 8:00 a.m. before school and 2:00 p.m.- 6:00 p.m. after school, Monday - Friday mid- August to early June and 6:45am – 6:00pm during the summer months. The facility was toured inside and outside, and the floor and yard plan submitted by the licensee were verified. Sign in/out records were reviewed and in compliance. Items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children located on high shelves out of reach of children. D1 stated there are no poisons in the facility, and none were observed during this inspection. LPA observed the toys, floors, desks and other equipment and surfaces are clean, toxic free, safe, and in good condition. There is uncontaminated drinking water available to children indoors and outdoors by use of individual water bottles or disposable cups of water, filled by sinks that tested in compliance for lead testing standards. The children's bathrooms are in safe and sanitary condition. The center’s isolation area for any child who becomes ill while in care is located in the office. LPA observed 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. Menus are posted in the school entry office area. There is a working smoke detector, carbon monoxide detector and fire extinguisher in the facility. LPA observed the playground equipment and surface areas were in safe condition.

Continued on LIC 809-C.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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 2


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: WOODSIDE WEST SCHOOL-AFTER SCHOOL PROGRAM
FACILITY NUMBER: 490108547
VISIT DATE: 01/25/2023
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There is wood chip cushioning underneath climbing structures and/or play equipment to absorb falls. There were no bodies of water observed on the site. D1 stated no weapons are stored on site, and none were observed.

During today's inspection, staffing ratios were being met, a total of 7 children were being supervised by 2 staff. The facility was operating within the licensed capacity and ratio requirements. There was at least one person (D1) with CPR/First Aid certification, which expires on 08/2024.

This facility provides Incidental Medical Services – IMS, however D1 stated that no children currently enrolled have IMS needs and no medication is currently stored at the facility. 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: http://www.ada.gov/childqanda.htm

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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

Exit interview conducted and report was reviewed with facility representative, Diana Dumbadse.

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: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023
LIC809 (FAS) - (06/04)
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