493002902-4-6-2023-01-CC-MMOR-CQN2BL-20230406171519

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 493002902
Report Date: 04/06/2023
Date Signed: 04/06/2023 05:15:36 PM

Document Has Been Signed on 04/06/2023 05:15 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	HEAD START - CLOVERDALE		FACILITY NUMBER:	493002902
ADMINISTRATOR:	CARLA BRUSSEAU		FACILITY TYPE:	850
ADDRESS:	322 WASHINGTON STREET		TELEPHONE:	(707) 894-9072
CITY:	CLOVERDALE	STATE: CA	ZIP CODE:	95425
CAPACITY:	20	CENSUS: 5	DATE:	04/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Mary Steele		TIME COMPLETED:	05:30 PM

NARRATIVE

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A required one-year inspection was made to the facility by Licensing Program Analyst (LPAs), Amy Strother and Mindy Mohr. LPAs met with facility representative, Center Director Mary Steele (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.

The facility’s operating days and hours are Monday-Thursday 8:00 a.m. - 2:45 p.m. The program runs mid- August to late June. 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 and 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. 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 in the quiet corner by the office. LPAs 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 on the parent board in the classroom. There is a working smoke detector, carbon monoxide detector and fire extinguisher in the facility. LPAs toured the outdoor play yard and observed three wooden boards on the edge of the deck that were splintered and decaying. Additionally, LPAs observed a wooden garden box that had loose metal hardware coming away from the wood and had sharp edges.

Continued on LIC 809-C.

SUPERVISOR'S NAME: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melinda Mohr	TELEPHONE: (707) 494-2125
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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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Document Has Been Signed on 04/06/2023 05:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HEAD START - CLOVERDALE	FACILITY NUMBER: 493002902
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

101238.2(d)(2)

Outdoor Activity Space

(d) The surface of the outdoor activity space shall be maintained: (2) Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation the edge of the deck was splintered and decaying on the edge of three wooden boards, also the garden box was observed to have loose metal hardware coming away from the wood and has sharp edges which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/13/2023
	Plan of Correction
1 2 3 4	Center Director will call maintenence either today or first thing tomorrow morning. In the meantime duct tape and construction cones will be used to prevent children from accessing the hazards. Director stated boards will be replaced and the metal pieces will be removed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melinda Mohr	TELEPHONE: (707) 494-2125
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HEAD START - CLOVERDALE	FACILITY NUMBER: 493002902
	VISIT DATE: 04/06/2023

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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 5 preschool children were being supervised by 2 teachers. The facility was operating within the licensed capacity and ratio requirements. All staff members present during the inspection possessed current CPR and First Aid certifications, D1’s certificate expires 8/2023.

Five children’s records were reviewed and contained complete and current information as required. Two staff files were reviewed and contained all records as required.

This facility provides Incidental Medical Services – IMS. 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: http://www.ada.gov/childqanda.htm

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

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.

Exit interview conducted and report was reviewed with facility representative, Mary Steele

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: Leslie Lepori	TELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melinda Mohr	TELEPHONE: (707) 494-2125
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC809 (FAS) - (06/04)

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