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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173011098
Report Date: 06/18/2026
Date Signed: 06/18/2026 10:21:49 AM

Document Has Been Signed on 06/18/2026 10:21 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NCO HEAD START - UPPERLAKEFACILITY NUMBER:
173011098
ADMINISTRATOR/
DIRECTOR:		MICAH HALEFACILITY TYPE:
860
ADDRESS:775 CLOVER VALLEY ROADTELEPHONE:
(707) 275-6003
CITY:UPPER LAKESTATE: CAZIP CODE:
95485
CAPACITY: 16TOTAL ENROLLED CHILDREN: 16CENSUS: 0DATE:
06/18/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Hyechong FroschlTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
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On 06/18/2026 Centralized Application Bureau (CAB) Licensing Program Analyst (LPA) Jaelyn Agbayani and LPA Sebastian Phouthavong met with Program Compliance Specialist, Hyechong Froschl. The purpose of the visit was an announced pre-licensing inspection at the facility to ensure the health, safety and personal rights as required by Title 22 and Health and Safety Regulations governing California Child Care Centers will be met. Applicant is requesting for a Change of Location with capacity of 16 preschool children ages 2.9-5 years old in the Preschool Classroom. The facility is currently operating under a preschool license # 173001847. Facility will be converting to a single license upon completion of this application process. The childcare center will operate from Monday, Tuesday, Thursday, and Friday from 08:00 AM-03:00 PM as well as Wednesday 08:00 AM-12:30 PM. The fire clearance was approved on 03/17/2026 by the Northshore Fire Protection District.

LPAs toured and measured the on-limits areas and classrooms located at the facility. The facility has a total of 1 classroom for the preschool component.

Preschool Classroom Measurements:

The indoor total measurements contain a total of 907.95 square feet, which will accommodate applicant’s request for 16 preschool children.

Preschool Outdoor Play Measurements:

The outdoor total measurements contain a total of 3,828.63 square feet, which will accommodate applicant’s request for 16 preschool children.

Report continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NCO HEAD START - UPPERLAKE
FACILITY NUMBER: 173011098
VISIT DATE: 06/18/2026
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All indoor and outdoor activity space utilized for the children were inspected today. LPAs informed applicant that staff are required to maintain direct visual supervision of the children at all times during indoor and outdoor activities. Classrooms were observed to be clean, safe, sanitary and in good repair. All outdoor and indoor passageways and other areas of potential hazard were free of obstruction. A comfortable temperature for children shall be maintained at all times.

Furniture and equipment were observed to be maintained in good condition, free of sharp, loose, or pointed parts. All materials and surfaces accessible to children, including toys, shall be free of toxic substances. All play equipment and materials used by children were observed to be age appropriate. Tables and chairs were observed to meet the needs of the children. There 2 toilets, 2 sinks, 4 tables, 16 cots, and 23 chairs available for preschool children. Isolation area for sick children will be the director’s office, children have access to staff bathroom and remain separated from remaining children. Facility has one preschool classrooms. Program Compliance Specialist stated that the facility provides breakfast, lunch, and snack for children. Per Program Compliance Specialist, drinking water is readily available for the children in the facility via water pitchers and water fountains.

The applicant shall take measures to keep the center free of flies, other insects, and rodents. All containers used for storage of solid wastes, including moveable bins, shall have a tight-fitting cover that is kept on. LPAs observed no fire place or open face heaters. Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children to accessible to staff. There is a fully equipped first aid kit and fire extinguisher stored where accessible to staff and inaccessible to children. There is an operational carbon monoxide detector on site.

LPAs observed the facility has a fully fenced outdoor playground for preschool children. Outdoor areas were free of hazards including, holes, broken glass dry grasses, and other debris that pose a fire hazard. Any construction or equipment that could pose a hazard in the outdoor activity areas shall be made inaccessible to children in care. Per Program Compliance Specialist, shade will be provided to children via shade structure and trees. The playground is enclosed by a fencing at least 4 feet high. There are sufficient outdoor age-appropriate toys and play equipment available on the playground. The areas around and under high climbing equipment had cushioned with material (woodchips) that absorb falls. LPAs observed a sandbox area. LPA advised that sandboxes should be inspected daily and shall be kept of hazardous foreign materials. LPA observed no bodies of water.

Report continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NCO HEAD START - UPPERLAKE
FACILITY NUMBER: 173011098
VISIT DATE: 06/18/2026
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Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010 to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5 years after the date of the first test as specified in Health and Safety Code section 1597.16. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP). LPAs referred center director to the Department website for lead: Lead Toxicity Prevention and Water Testing information (https://www.cdss.ca.gov/inforesources/child-care-licensing/water-testing-information)

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (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.

Center Director was reminded that all adults 18 and over, including, employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Applicant was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Report continued on LIC 809-C.

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NCO HEAD START - UPPERLAKE
FACILITY NUMBER: 173011098
VISIT DATE: 06/18/2026
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquires 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/inspection-process.

An exit interview was conducted with the above item discussed.

This report and appeal rights were provided to Hyechong Froschl, Program Compliance Specialist.

Effective today, 06/18/2026, this facility is licensed for 16 preschool children.

NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2026
LIC809 (FAS) - (06/04)
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