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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009258
Report Date: 06/14/2019
Date Signed: 06/17/2019 03:59:15 PM

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: 19DATE:
06/14/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Michelle MartinTIME COMPLETED:
11:30 AM
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A case management inspection visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang in response to an incident that occurred at the center on 06/03/19 involving child C1. The site supervisor (staff S1) reported that on 06/03/19 at 08:00am, while in the classroom, child C1 ran past staff S2 and then reached over and opened the classroom's half-door, which separates the classroom from the facility's main entrance and site supervisor's office. Staff S1 reported that as child C1 reached over to open the half-door, staff S2 verbally notified her that child C1 was exiting the classroom. Staff S1 stated that she stepped out of her office to tell child C1 to "stop" but child C1 did not respond and continued proceeding towards the facility's main entrance. Staff S1 reported that she then tailgated child C1 as the child exited the facility's main entrance. The area immediately outside of the facility's main entrance is completely surrounded by a chain link fence that is at least six feet tall. Staff S1 reports that she maintained direct visual supervision of child C1 the entire time child C1 was outside the classroom. Staff S1 reported that she escorted child C1 back to the classroom and notified the child's guardian of the incident and reminded child C1 that it was not safe to run out of the classroom.

During today’s inspection, there were 19 children in care being supervised by five staff members. Children were observed to be directly supervised by staff while playing indoors and outdoors. LPA observed a door chime installed on the classroom's half door and the facility's main entrance door. In addition, LPA also observed a child proof door lever lock installed on the classroom's half door. Staff S1 stated that the lever lock was installed as a response to the incident involving child C1 and as a precaution against future incidents of a similar nature. This incident was reported to CCLD as required.

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: 06/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019
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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