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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233009679
Report Date: 06/23/2023
Date Signed: 06/23/2023 03:57:35 PM

Document Has Been Signed on 06/23/2023 03:57 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:IMAGINATION STATION-INFANT CENTERFACILITY NUMBER:
233009679
ADMINISTRATOR:RODRIGUEZ, SAPRINAFACILITY TYPE:
830
ADDRESS:262 EAST COMERCIAL STREETTELEPHONE:
(707) 459-6543
CITY:WILLITSSTATE: CAZIP CODE:
95490
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: DATE:
06/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Lorenzo Rodriguez TIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Robert Maciel and Mindy Mohr made an unannounced case management inspection to the facility while attending to other matters in the facility. During today's inspection, LPAs met with facility representative, Lorenzo Rodriguez, Staff 1 (S1). During today's inspection, LPAs observed Child (C1) asleep on their stomach. LPA requested to review the required form LIC 9227 Individual Infant Sleeping Plan for C1. The facility did not have the LIC 9227 on file for C1.

The following violations of the California Code of Regulations, Title 22; Division 12 were observed during today's inspection. See LIC 809-D for deficiency cited during today's inspection.


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.

This report was reviewed and discussed with facility representative, Lorenzo Rodriguez. Appeal Rights were provided.

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.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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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Document Has Been Signed on 07/18/2023 10:31 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 07/06/2023 02:05 PM


Created By: Robert Maciel On 06/23/2023 at 02:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: IMAGINATION STATION-INFANT CENTER
FACILITY NUMBER: 233009679

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2023
Section Cited
HSC
101430(a)(3)(A)

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Staff shall place infants up to 12 month of age on their backs for sleeping.

This requirement was not met as evidenced by:
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Licensee states all infants will always be placed on their back while sleeping.

Teachers will refresh their safe sleep training course.
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Based on LPA's observations infant was in a crib, asleep on their stomach which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
06/23/2023
Section Cited
HSC101419.2(b)(2)

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The needs and services plan shall be in writing and shall include the following:

Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan [LIC 9227 (3/20)], which is incorporated by reference.

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Licensee states the LIC 9227 form shall be completed for each infant.
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(A) This plan shall be signed and dated by the infant’s authorized representative
This requirement was not met as evidenced by:

Based on record review LIC 9227 Individual Infant Sleeping Plan was not available tor review.
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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.
SUPERVISOR'S NAME:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2023


LIC809 (FAS) - (06/04)
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