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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493004931
Report Date: 03/04/2020
Date Signed: 03/04/2020 01:33:48 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 CENTERFACILITY NUMBER:
493004931
ADMINISTRATOR:DIAZ, ANDREAFACILITY TYPE:
850
ADDRESS:305 W. PAYRAN STREET, STE #CTELEPHONE:
(707) 782-0408
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:42CENSUS: 31DATE:
03/04/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Andrea DiazTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Jennifer Velasco conducted an unannounced case management inspection re: an Unusual Incident Report (UIR) filed by the director (D1) about a 02/07/2020 incident in which at 4:40 p.m., a child (C1) and a child (C2) were observed by a staff (S1) engaging in inappropriate contact with each other. S1 reported immediately intervening and discussing the incident with C1 and C2. S1 stated they notified D1, who reported the incident as required.

During today's inspection, LPA toured the facility, obtained facility documents, qualified and interviewed one child (C1), interviewed one staff (S1), met with the director (D1), and observed eight staff providing care and supervision to 31 children. No deficiencies were cited during this inspection.

Notice of Site Visit to be posted for 30 days.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
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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