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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009957
Report Date: 08/03/2021
Date Signed: 08/03/2021 07:20:42 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:CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTER-S/AFACILITY NUMBER:
493009957
ADMINISTRATOR:BOEHM, JEANETTEFACILITY TYPE:
840
ADDRESS:530 NORTH CLOVERDALE BLVDTELEPHONE:
(707) 894-6037
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:9CENSUS: 2DATE:
08/03/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Jeanette BoehmTIME COMPLETED:
07:20 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
While Licensing Program Analyst (LPA) Amy Strother was conducting an investigation related to another matter, LPA conducted in interviews with Staff 1 (S1), Staff 3 (S3), Staff (S5) and Staff 6 (S6) on 04/15/21, 04/27/21, 04/28/21 and 04/29/21, staff interviewed stated that the school-age children have joined the preschool and toddler children for lunch in the preschool room and played with the preschool children on the playground and in the classroom on more than one occasion.

During today's unannounced investigation inspection LPA met with Licensee, Jeanette Boehm (L1). During a tour of the facility, L1 stated that 2 of the children in the preschool room were school age children, who joined the preschool room when L1 needed to take a phone call. During the inspection visit, LPA observed two school-age children, Child 1 and Child 2 (C1 and C2) present in the preschool classroom for free play time after lunch, rest time and after rest play time.

The following violation of the California Code of Regulations, Title 22; Division 12, were cited: see LIC 809-D. Appeal Rights were provided.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
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.
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, 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

1
2
3
4
5
6
7
101538.3 Indoor Activity Space for School-Age Children (b)In combination programs, indoor activity space provided for school-age child care center children shall be physically separated from space provided for infant care and child care center children. This requirement was not met as evidenced by:

8
9
10
11
12
13
14
Based on today's LPA observations and interviews conducted with S1, S3, S5, S6 school-age children have joined the preschool and toddler children for lunch in the preschool room and played with the preschool children on the playground on more than one occasion. This poses a potential risk to the children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
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
LIC809 (FAS) - (06/04)
Page: 2 of 2