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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493004901
Report Date: 10/15/2019
Date Signed: 10/15/2019 02:41:17 PM

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:W. H. PEPPER PRESCHOOL INC.FACILITY NUMBER:
493004901
ADMINISTRATOR:WASIELEWSKI, CAROLYNFACILITY TYPE:
850
ADDRESS:627 F STREETTELEPHONE:
(707) 762-8151
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:25CENSUS: 21DATE:
10/15/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Erica LewisTIME COMPLETED:
12:30 PM
NARRATIVE
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An unannounced inspection was made to the facility by Licensing Program Analyst (LPA) J. Velasco. The facility file was reviewed prior to this inspection. 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.

The facility’s operating hours are 8:30 a.m. - 3:00 p.m., Monday - Wednesday, and 8:30 a.m. - 11:30 a.m. Thursday - Friday, September - June. 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 in locked cupboards below the kitchen sink and in high, locked cupboards in the bathroom. Director stated there are no poisons in the facility, and none were observed during this inspection.

The toys, floors, desks and other equipment and surfaces are clean, toxic free, safe, and in good condition. There is drinking water available to children both indoors and outdoors by use of insulated water jugs and individual cups for children on the playground and in the classrooms. The children's bathroom is in safe and sanitary condition.

Facility provides one snack per day. LPA observed a posted menu. 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.

Continued on LIC 809-C.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
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 3
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: W. H. PEPPER PRESCHOOL INC.
FACILITY NUMBER: 493004901
VISIT DATE: 10/15/2019
NARRATIVE
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Continued from LIC 809.

LPA observed a working carbon monoxide detector in the facility. 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 on the site. Director stated no weapons are stored on site, and none were observed. During today's inspection, staffing ratios were being met, and 21 children were being supervised by two staff. The facility was operating within the licensed capacity and ratio requirements. At least one staff member present during the inspection possessed current CPR and First Aid certifications, which expire in 06/2020. Five children’s records were reviewed at 10:00 a.m. and contained signed admission agreements and immunization records or medical exemptions as required. Three staff records were reviewed at 10:30 a.m. and contained documentation of education and training as required.

This facility is not currently providing Incidental Medical Services (IMS) and has a Plan of Operation on file with the Department. The Department’s IMS policy was discussed with the Director. The facility plans to have an IMS Plan of Operation on file with the Department. 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.
The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: W. H. PEPPER PRESCHOOL INC.
FACILITY NUMBER: 493004901
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2019
Section Cited

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Personnel Records. Personnel records shall be maintained on the licensee, administrator, and each employee, and shall contain specified information. This standard has not been met as evidenced by :
LPA's 10:30 a.m., 10/15/19 review of staff records, during which LPA
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observed that staff files for three staff (S1-S3) were missing both LIC 503 and proof of immunity against Measles.
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Fax: 707-588-5099
Email:
jennifer.velasco@dss.ca.gov

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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: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3