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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110022
Report Date: 07/18/2019
Date Signed: 07/18/2019 05:32:14 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:A SPECIAL PLACEFACILITY NUMBER:
490110022
ADMINISTRATOR:WENDY ADAMSFACILITY TYPE:
850
ADDRESS:1128 EDWARDS AVENUETELEPHONE:
(707) 523-2337
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:30CENSUS: 22DATE:
07/18/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:08 PM
MET WITH:Wendy Adams TIME COMPLETED:
05:45 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 program is operated by YWCA a Title 5 funded program.

The facility’s operating hours are 8:00 a.m.- 3:30 p.m., Monday-Friday. 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 there are no poisons on the premises and none were observed during today's inspection. 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 both indoors and outdoors provided by a water jug and paper cups. 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. At 2:42 p.m. the director stated that the facility does not have 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 rubber chip 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, in the main classroom where 7 children were being supervised by one teacher, and in the nap room where 12 sleeping children were being supervised by one teacher. Outside, LPA observed 3 children with one adult (A1) who is not a fully qualified teacher. LPA interviewed the director and reviewed staff files and it was verified that A1 does not have the required educational units to supervise children without a fully qualified teacher present. At least one staff member present during the visit (S2) possessed current CPR and First Aid certifications.
Continue on LIC809-C
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
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 4
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: A SPECIAL PLACE
FACILITY NUMBER: 490110022
VISIT DATE: 07/18/2019
NARRATIVE
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The sign-in/sign-out procedure was reviewed and in compliance. Six children’s records were reviewed at 3:15 p.m., and contained signed admission agreements. Two staff records were reviewed at 3:30 p.m. and although one contained documentation of education and training as required, A1's did not. The director stated that documents relating to staffs medical history, including immunization records are located at the YWCA administrative office. The administrative office was not able to provide the records to LPA at today's inspection. The director stated that she will go the administrative office on 7/19/19 and email proof of staff immunization to LPA on 7/19/19. This facility is is not currently providing Incidental Medical Services (IMS) as the director stated that none of the children currently enrolled require IMS. The Department’s IMS policy was discussed with the Director. 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, The Effects of Lead Exposure brochure and the Community Care Licensing website, 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(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

Reports citing Type A violations are to be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.



An exit interview was conducted and Plans of corrections were reviewed and developed with the Director. Appeal Rights were provided and discussed with, Wendy Adams 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: 07/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: A SPECIAL PLACE
FACILITY NUMBER: 490110022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2019
Section Cited
CCR
101216.1(b)
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Teacher Qualifications and Duties (b) Prior to employment...(1) A teacher shall have completed, with passing grades, at least six postsecondary semester or equivalent...
This requirement was not met as evidenced by:
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The director stated that she will hold an all staff meeting on 7/22/19 and cover the topic of staffing requirements and how to schedule lunch breaks appropriately so that a fully qualified teacher is present with children as required.
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Based on observation, interview and record review, the licensee failed to have a fully qualified teacher on the play ground with three children, which poses a potenial Health, Safety or Personal Rights risk to the children in care.
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The director stated that she will email a copy of the staff meeting notes and agenda signed by staff in attendance.
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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: 07/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: A SPECIAL PLACE
FACILITY NUMBER: 490110022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/19/2019
Section Cited
HSC
1596.954
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Carbon monoxide detectors required;...Every licensed child day care center shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. ...during inspections.
This requirement was not met as evidenced by:
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Director stated that she will purchase and install a working carbon detector on 7/19/19 and send LPA a photo and video.
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Based on interview and observation, the licensee failed to have a working carbon monoxide detector in the facility, which poses a potential Health, Safety, or Personal Rights risk to the children in care.
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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: 07/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4