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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010019
Report Date: 03/09/2022
Date Signed: 03/09/2022 03:03:57 PM


Document Has Been Signed on 03/09/2022 03:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:4CS MEADOW PRESCHOOLFACILITY NUMBER:
493010019
ADMINISTRATOR:IMAN SENANFACILITY TYPE:
850
ADDRESS:880 MARIA DRIVETELEPHONE:
(707) 544-3077
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:43CENSUS: 26DATE:
03/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Andrea EstupinanTIME COMPLETED:
01:40 PM
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A required annual inspection of the facility was conducted by Licensing Program Analyst Jennifer Velasco (LPA). The facility file was reviewed prior to this inspection. A review of the personnel report on file indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The staff was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. 4Cs Meadow Preschool is located on the campus of Meadow School. LPA met with 4Cs staff Andrea Estupinan (S1). The facility’s operating hours are 7:00 a.m. - 5:30 p.m., Monday-Friday, year-round. One program is half day and one is full day. The facility was toured inside and outside, and the floor and yard plan submitted by the licensee were verified. Sign in/out records were reviewed and found to be in compliance. Items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children on upper cabinets out of reach of children. S1 stated there are no poisons in the facility, and none were observed during this inspection. LPA observed the toys, floors, desks, and other equipment and surfaces are clean, toxic free, safe, and in good condition. There is drinking water available to children both indoors and outdoors by use of individually labelled water cups or bottles indoors and outdoors. The children's bathrooms are in safe and sanitary condition. The center’s isolation area for any child who becomes ill while in care is located in the staff office. LPA observed food prep areas are clean. Food is properly stored and refrigerated as needed. There was no contaminated food observed. Garbage cans containing solid waste have tight fitting lids. Menus are posted in the front entrance of the facility at least one week in advance, as required. LPA observed a working carbon monoxide detector in the facility. LPA observed the playground equipment and surface areas are in safe condition. There is sufficient wood chip cushioning underneath climbing structures and/or play equipment to absorb falls. There were no bodies of water observed on the site. S1 stated no weapons are stored on site, and none were observed.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: 4CS MEADOW PRESCHOOL
FACILITY NUMBER: 493010019
VISIT DATE: 03/09/2022
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During today's inspection, staffing ratios were met, with 26 children supervised by six staff. The facility was operating within licensed capacity and ratio requirements. At least one staff member present during the inspection possessed current CPR and First Aid certifications, which expire 4/2023. Ten children’s records were reviewed at 12:10 p.m. and contained all required documents. Seven staff records were reviewed and contained the required documents. Incidental Medical Services (IMS) policy was discussed. The facility has an IMS plan of operation on file with the Department. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. There were no Title 22 deficiencies cited during today's inspection. Exit interview was conducted and report was reviewed with S1. To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
LIC809 (FAS) - (06/04)
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