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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 493009957
Report Date: 08/03/2021
Date Signed: 08/03/2021 07:09:12 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2021 and conducted by Evaluator Amy Strother
COMPLAINT CONTROL NUMBER: 01-CC-20210413085226
FACILITY NAME:CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTER-S/AFACILITY NUMBER:
493009957
ADMINISTRATOR:BOEHM, JEANETTEFACILITY TYPE:
840
ADDRESS:530 NORTH CLOVERDALE BLVDTELEPHONE:
(707) 318-3951
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:9CENSUS: 2DATE:
08/03/2021
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jeanette BoehmTIME COMPLETED:
07:08 PM
ALLEGATION(S):
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Children are not being supervised adequately
Authorized Representatives are not being communicated to about incidents

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Strother made a subsequent complaint investigation inspection for the purpose of delivering the findings, and met with Licensee, Jeanette Boehm (L1). It has been alleged that children are not being supervised adequately and Authorized Representatives are not being communicated to about incidents.

During the initial complaint investigation Tele-visit to the facility on 04/21/21, LPA met with L1 using Zoom at 12:18pm. During an interview with L1 on 04/21/21, L1 denied the allegations, stating that children are always supervised and that L1 communicates all incidents to parents, and could not think of an incident happening that was not communicated to the parents.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 01-CC-20210413085226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTER-S/A
FACILITY NUMBER: 493009957
VISIT DATE: 08/03/2021
NARRATIVE
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Five staff (S1-S3 and S5-S6) were interviewed on 04/20/21, 04/27/21, 04/28/21, 04/29/21 and 07/22/21. Records were received and reviewed on 05/04/21 and 05/26/21.
Staff interviews corroborate that on more than one occasion when L1 was working as the school age teacher and using the infant room as the school-age classroom, L1 left the room, leaving the school age children unsupervised while they were on their Zoom classes. Staff interviewed stated that L1 told staff that they were not allowed to communicate with the children’s Authorized Representatives and that it was her job to do so. Staff corroborated that L1 was often not present at the facility and therefore did not know when an incident between children had occurred, specifically stating that a school age child kicked a ball, hitting another child in the face and the incident was not reported to the child’s Authorized Representative.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal rights were provided and exit interview conducted.

Reports citing Type A violations are to be provided to parents/guardians of children currently enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC 9224 to be kept in each child's file.

The Notice of Site Visit must be posted for 30 days.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 01-CC-20210413085226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTER-S/A
FACILITY NUMBER: 493009957
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2021
Section Cited
CCR
101229(a)(1)
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No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.

This requirement is not met as evidenced by:
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L1 stated that the children will never be left unsupervised except when using the bathroom one student at a time. L1 stated that supervision including visual observation will be discussed at the staff meeting on 08/29/21 after new staff have been hired.
L1 will submit staff training notes to LPA on 08/30/21.
amy.strother@dss.ca.gov
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Based on staff interviews corroborating that on more than one occasion the children were left in the classroom unsupervised. This poses an immediate health and safety risk to the children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 01-CC-20210413085226
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTER-S/A
FACILITY NUMBER: 493009957
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2021
Section Cited
CCR
101226(a)(2)
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(a)The licensee shall immediately notify the child's authorized representative…(2) In the case of less serious injuries including, but not limited to, minor cuts, scratches…the licensee shall document the injury in the child's record and notify the child's authorized representative of...injury when the child is picked up from the center. This requirement is not met as evidenced by:
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L1 stated that she has used text messages to communicate to parents or spoken to parents after staff are not present and staff are not aware of the communication. L1 stated that beginning 08/04/21 L1 will use the Brightwheel program to record "boo-boo reports" so that teachers can observed reports and also record any incidents that they observe.
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Based on staff interview, L1 has instructed staff that they may not communicate with children’s authorized representative’s, injuries have occurred, and L1 was not present at the facility to report the incident. This poses a potential health and safety risk to the children in care.

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L1 stated that each child's authorized representative has access to their child's profile on Brightwheel.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4