<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493004931
Report Date: 05/11/2023
Date Signed: 05/11/2023 04:26:57 PM


Document Has Been Signed on 05/11/2023 04:26 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:4CS OLD ELM CHILD DEVELOPMENT CENTERFACILITY NUMBER:
493004931
ADMINISTRATOR:FANNY SALASFACILITY TYPE:
850
ADDRESS:305 W. PAYRAN STREET, STE #CTELEPHONE:
(707) 782-0408
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:42CENSUS: 28DATE:
05/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Fanny SalasTIME COMPLETED:
04:41 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 annual required inspection was made to the facility by Licensing Program Analyst (LPA), Y. Yang. The facility file was reviewed prior to this inspection. A review of the personnel report on 05/11/23 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 Center Director 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 LPA met with the facility's Site Supervisor,Fanny Salas today. The facility’s operating hours are 07:30am-05:30pm, Monday-Friday. The facility was toured inside and outside and the floor and yard plan submitted by the licensee were verified. The toys, floors, desks and other equipment and surfaces were clean, free of toxins, safe and in good condition. The facility was free of flies, insects and rodents. There is drinking water available to children both indoors in the classrooms and outdoors on the playground. The children’s bathrooms were in sanitary condition. Food prep areas are clean. Food is properly stored and free of contamination. A current menu was posted by the classroom's main entrance. Garbage cans containing solid waste were in good repair and had tight fitting lids. The facility's play yards are fully fenced and free of hazards. There is wood chip cushioning on the playground. There were no bodies of water observed. The Site Supervisor stated no weapons or poisons are stored on site. There are smoke and carbon monoxide detectors in the classroom. During today's inspection the facility was operating within the licensed capacity. At least one staff member present during the visit possessed current CPR and First Aid certifications. The sign in/out procedure was reviewed and was in compliance with regulations. Ten children's children's records were reviewed and contained identification forms with authorized representative information, as well as medical assessment forms. Seven staff files were reviewed and contained the required documents as specified on the inspection checklist. Continued on LIC 809-C
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: 4CS OLD ELM CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 493004931
VISIT DATE: 05/11/2023
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
26
27
28
29
30
31
32
Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. 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.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Site Supervisor Fanny Salas. There were no Title 22 deficiencies cited during today's annual inspection.

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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2