<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490109162
Report Date: 08/04/2021
Date Signed: 08/04/2021 11:56:08 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:OLD ADOBE SCHOOLFACILITY NUMBER:
490109162
ADMINISTRATOR:MURRAY, MICHAELAFACILITY TYPE:
850
ADDRESS:252 WEST SPAIN STREETTELEPHONE:
(707) 408-2383
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:30CENSUS: 14DATE:
08/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Michaela Murray, DirectorTIME COMPLETED:
11:55 AM
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
Licensing Program Analysts (LPA), Kevin O'Connell made an unannounced Case Management visit and met with the Center Director, Michaela Murray (S1) to deliver this report and citation. During the course of a complaint investigation, LPA O'Connell obtained evidence showing that a staff member (S3) was working without criminal clearance association. S1 reported to LPA that she found the clearance in the file and sent it in immediately.

This will be cited as a "B" violation as the Director self reported to LPA that the clearance transfer paperwork was in file but the follow-up to associate was overlooked but processed immediately after finding the omission. LPA O'Connell verified the correction showing that S3 was associated shortly after the self reporting.
Please see 809d for deficiency. Appeal Rights were given. Notice of Site Visit is to be posted for 30 days.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
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,
, CA

FACILITY NAME: OLD ADOBE SCHOOL
FACILITY NUMBER: 490109162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2021
Section Cited

1
2
3
4
5
6
7
(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to
8
9
10
11
12
13
14
(2) Request a transfer of a criminal record clearance as specified in Section 101170(f).
This requirement is not met as evidenced by: Based on interviews conducted and fingerprint document/record reviews, the licensee failed to ensure that S3's criminal record clearance was not associated to this facility before working. This poses a potential health and safety risk to children in care.
8
9
10
11
12
13
14
Fingerprint & criminal record information and will submit a statement of acknowledgement of review and understanding to CCL by 8/18/21.
kevin.oconnell@dss.ca.gov
707 494-2125

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2