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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493000369
Report Date: 05/31/2019
Date Signed: 05/31/2019 04:00:18 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:R.L. STEVENS EXTENDED CHILD CAREFACILITY NUMBER:
493000369
ADMINISTRATOR:WILSON, DORISFACILITY TYPE:
840
ADDRESS:2345 GIFFEN AVENUETELEPHONE:
(707) 579-2627
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:112CENSUS: 43DATE:
05/31/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Michelle DominguezTIME COMPLETED:
04:15 PM
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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 Extended Child Care, a nonprofit agency. At 2:24 p.m. Director, Michelle Dominguez stated that all children's files and staff files are stored off site at the Extended Child Care main office located at 1745 Copperhill Pkwy Ste. #5 Santa Rosa, CA 95403.

The facility’s operating hours are 7:00 a.m. - 8:45 a.m. before school and 12:00 p.m.- 6:00 p.m. after school, Monday - Friday mid- August to early June. During the summer months, early June to mid-August, the operating hours are 7:00 a.m. - 6:00 p.m. 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 poisons are not stored 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 with both a jug of water with paper cups and a drinking fountain. 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. The LPA observed 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 wood 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, and 43 children were being supervised by the director, 1 teacher, 1 assistant teacher and 1 substitute assistant teacher. The facility was operating within the licensed capacity.
Continue on LIC809-C
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019
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 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: R.L. STEVENS EXTENDED CHILD CARE
FACILITY NUMBER: 493000369
VISIT DATE: 05/31/2019
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LPA could not verify that at least one staff member present during the visit possessed current CPR and First Aid certifications because the files are stored at the main office listed above. LPA will visit the main office on a later date to verify CPR and first Aid certifications. The sign-in/sign-out procedure was reviewed and in compliance. This facility is not providing Incidental Medical Services (IMS). 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 brochures, 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 HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2019
LIC809 (FAS) - (06/04)
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