493009957-8-18-2021-01-CC-ASTR-C623S8-20210818182954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 493009957
Report Date: 08/18/2021
Date Signed: 08/18/2021 06:30:00 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/A		FACILITY NUMBER:	493009957
ADMINISTRATOR:	BOEHM, JEANETTE		FACILITY TYPE:	840
ADDRESS:	530 NORTH CLOVERDALE BLVD		TELEPHONE:	(707) 894-6037
CITY:	CLOVERDALE	STATE: CA	ZIP CODE:	95425
CAPACITY:	9	CENSUS: 6	DATE:	08/18/2021
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	Jeanette Boehm		TIME COMPLETED:	06:45 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	An unannounced Plan of Correction Visit was conducted by Licensing Program Analyst (LPA) Amy Strother. The purpose of the visit was to review the status of the Plan Of Corrections requested during a complaint investigation inspection on 08/03/21. During the visit on 08/03/21 Licensee, Jeanette Boehm (L1) was cited a Type B deficiency for failing to communicate with children's authorized representatives when injuries occurred. L1's plan of correction stated that beginning 08/04/21 L1 and staff would begin to use the BrightWheel application to communicate any injuries to the children's authorized representatives. During today's visit L1 stated that no school age children has sustained injuries, but was able to provide proof that on 08/04/21 and 08/11/21 the BrightWheel application was used to communicate injuries to children of preschool children. LPA determined that the use of the application meets to plan of correction. Deficiency was cleared. During the visit on 08/03/21 L1 was cited a Type A deficiency based on staff interviews corroborating that on more than one occasion the children were left in the classroom unsupervised. During today's inspection, LPA observed the School Age children to be under direct supervision at all times, therefore clearing the deficiency. L1's Plan of Correction also included plans to discuss supervision requirements at a staff meeting to be held on 08/29/21 once new staff is hired. L1 will submit staff meeting notes to LPA Strother on 08/30/21. LPA attempted to verify that the Parents/guardians of the school age children in attendance today had signed a form LIC9224. L1 was able to provide 3 signed LIC9224 forms out of the 6 school age in attendance. L1 was not able to provide LIC9224 forms for Child 1 - Child 3 (C1-C3) During the visit on 08/03/21 L1 was cited a Type B deficiency for failing to have a qualified teacher in ratio with the school age children. L1's Plan of Correction stated that she has hired two new fully qualified teachers, stating one teacher will start 08/09/21 assigned as a floater covering breaks and subbing as needed in preschool or school-age room. The second will start on 08/17/21 assigned as a second preschool teacher. Continue on LIC809-C

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

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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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
	VISIT DATE: 08/18/2021

NARRATIVE

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When LPA Strother arrived at the facility for today's POC inspection, L1 was not present at the facility. LPA went out to the School Age playground and observed 21 children in care with one teacher, Staff 1 (S1) and one aide, Staff 2 (S2) The 21 children present were both School Age and Preschool age children. When L1 arrived to the facility at approximately 10:35am, L1 took 6 school-age children to the preschool room to gather their personal items and escorted the 6 children to the school age classroom. Prior to L1's arrival, the School Age children did not have a qualified teacher in ratio. Therefore the Plan of Correction has not been met. A Civil Penalty has been accessed. See LIC421FC.

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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC809 (FAS) - (06/04)

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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: 08/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/20/2021 Section Cited	1 2 3 4 5 6 7	(c)(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b. This requirement has not been met as evidenced by:
	8 9 10 11 12 13 14	Based on file review, Child 1 - Child 3 (C1-C3) files did not contain a signed form LIC9224 required after receiving a Type A citation on 08/03/21.	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 Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy Strother	TELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021

LIC809 (FAS) - (06/04)

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