493004931-12-13-2019-01-CC-JVEO-BJTT6M-20191213132723

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 493004931
Report Date: 12/13/2019
Date Signed: 12/13/2019 01:27:44 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:	4CS OLD ELM CHILD DEVELOPMENT CENTER		FACILITY NUMBER:	493004931
ADMINISTRATOR:	DIAZ, ANDREA		FACILITY TYPE:	850
ADDRESS:	305 W. PAYRAN STREET, STE #C		TELEPHONE:	(707) 782-0408
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94952
CAPACITY:	42	CENSUS: 29	DATE:	12/13/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Andrea Diaz		TIME COMPLETED:	01:30 PM

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	An inspection was made to the facility by Licensing Program Analyst (LPA) Jennifer 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 7:00 a.m. – 5:30 p.m. Monday – Friday, year round. 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 the inaccessible janitor's closet, secured by a key locked door. 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 water fountains in the classrooms and on the playground. The children's bathrooms are in safe and sanitary condition. Facility provide breakfast, lunch, and one snack for children. LPA observed posted menus for breakfast, lunch, and afternoon snack. Food prep areas were observed to be clean. Food was observed to be 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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2019

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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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: 4CS OLD ELM CHILD DEVELOPMENT CENTER	FACILITY NUMBER: 493004931
	VISIT DATE: 12/13/2019

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 29 children were being supervised by eight 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 04/2021. Nine children’s records were reviewed at 12:30 p.m. and contained signed admission agreements and immunization records or medical exemptions as required. Four staff records were reviewed at 1:00 p.m. and contained documentation of education and training as required.

This facility is currently providing Incidental Medical Services (IMS) and has a Plan of Operation on file with the Department as needed. 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.

There were no Title 22 deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer Velasco	TELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2019

LIC809 (FAS) - (06/04)

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