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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493006190
Report Date: 04/12/2023
Date Signed: 04/12/2023 11:37:00 AM


Document Has Been Signed on 04/12/2023 11:37 AM - 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:4CS WINDSOR STATE PRESCHOOLFACILITY NUMBER:
493006190
ADMINISTRATOR:MICHELLE MARTINFACILITY TYPE:
850
ADDRESS:79 PLEASANT AVENUETELEPHONE:
(707) 836-7068
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:40CENSUS: 22DATE:
04/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Michelle MartinTIME COMPLETED:
11:45 AM
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On 04/12/2023, Licensing Program Analyst (LPA), Sebastian Phouthaovong made an unannounced Case Management visit to follow up on an Unusual Incident Report (UIR) submitted to CCL on 0/10/2023. LPA met with Site Supervisor, Michelle Martin spoke with her the regarding UIR involving a child.

During today's inspection, LPA toured the facility inside and out and observed 22 children being supervised by 5 staff members. LPA conducted interviews with the Site Supervisor and three staff member, reviewed facility documents and received documents

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, Michelle Martin

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

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2023
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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