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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009258
Report Date: 05/08/2019
Date Signed: 05/09/2019 08:47:45 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:4CS CLOVERDALE PRESCHOOLFACILITY NUMBER:
493009258
ADMINISTRATOR:MCINTYRE, AMYFACILITY TYPE:
850
ADDRESS:330 N. WASHINGTON STREETTELEPHONE:
(707) 894-9011
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:30CENSUS: 25DATE:
05/08/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Michelle MartinTIME COMPLETED:
12:51 PM
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A Case Management inspection was conducted at the facility by Licensing Program Analyst (LPA) Y. Yang in response to an Unusual Incident Report (UIR) received 05/02/2019 involving a possible lack of supervision resulting in inappropriate interactions between children in care. This incident was cross-reported by the facility to Child Protective Services (CPS) as well. On 05/08/19, LPA interviewed site supervisor Michelle Martin (S1), staff member S2, S3, S4, and S5 regarding the incident. According to the incident report and interviews conducted with staff, on 05/01/2019 at 12:30pm, two children (C1 and C2) were using the children's bathroom and being supervised by staff (S2). Staff interviewed reported that a child care client arrived at the center and began speaking with staff S2 as S2 was supervising the two children in the bathroom. The facility's children's bathroom is situated near the front entrance of the classroom and near the facility's sign in/out book. It was reported that as S2 was speaking with the childcare client, C3 approached staff S2 and informed S2 that child C1 and C2 were engaged in inappropriate activity in the bathroom. S2 reported that both C1 and C2 were fully clothed and that no inappropriate activity occurred in the bathroom.

Interviews with S1 S3,S4, and S5 corroborated that S2 was directly supervising C1 and C2. Interviews also corroborated that as C2 was speaking with the childcare client, C2 was positioned near the entrance to the children's bathroom.

During today’s inspection, there were 25 children in care being supervised by five staff members. Children were observed to be directly supervised by staff while playing indoors and outdoors and when toileting.

Based on interviews conducted, the LPA was unable to determine if any incident occurred between C1 and C2 due to a lack of supervision.

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. This report was reviewed and discussed with site supervisor.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2019
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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