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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283010138
Report Date: 05/14/2024
Date Signed: 05/14/2024 01:32:33 PM

Document Has Been Signed on 05/14/2024 01:32 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:HOPPER CREEK MONTESSORIFACILITY NUMBER:
283010138
ADMINISTRATOR/
DIRECTOR:		TAMARA KINMANFACILITY TYPE:
850
ADDRESS:2141 2ND STREETTELEPHONE:
(707) 231-8768
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY: 35TOTAL ENROLLED CHILDREN: 35CENSUS: 13DATE:
05/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:59 AM
MET WITH:Tamara KinmanTIME VISIT/
INSPECTION COMPLETED:
01:37 PM
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During the course of a complaint investigation, an additional deficiency was identified during children's record review, which revealed that parents or guardians were not provided a copy of the licensing report dated 02/15/2024, which documented two Type A citations that represented an immediate risk to the health, safety, or personal rights of children in care. S1 stated they were not aware the report was to be provided to newly enrolled families. The report dated 02/15/2024 was not provided upon enrollment to the parents of 4 newly enrolled children (C1 - C4) and 1 child (C5) who was currently enrolled at the time of the report, resulting in the non-compliance of Health and Safety Code 1596.8595 (c)(2).

In addition, the Fire Department was called to the facility on 05/10/2024 at approximately 3:00 pm due to the smoke detectors activating. S1 stated it was determined by fire personnel that the switch on the wall heater had been bumped and switched on when the children's nap mats were put away, causing the heater to turn on and burn off dust. The heater did not catch fire, and there was no damage to the building. The children were outside when the smoke detector activated and remained outside until their parents arrived to pick them up. The Licensee has since put a barrier between the nap mats and the heater and has turned off power to the heater. S1 reported the incident via telephone to the Department as required.


The following violation of the Health and Safety Code was issued: see LIC 809D. Appeal Rights were provided.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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 05/14/2024 01:32 PM - It Cannot Be Edited


Created By: Melinda Mohr On 05/14/2024 at 11:34 AM
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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HOPPER CREEK MONTESSORI
FACILITY NUMBER: 283010138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/14/2024
Section Cited
HSC
1596.8595(c)(2)

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 (2) Upon enrollment of a new child in a facility, the licensee shall provide to the parents or legal guardians of the newly enrolling child copies of any licensing report that the licensee has received during the prior 12-month period 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.
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Director stated that she will ensure that parents of C1 - C5 will sign and date the LIC9224 forms and will scan and email signed copies of the LIC9224 forms to LPA Mohr by 05/17/24 at Melinda.mohr@dss.ca.gov
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This requirement is not met as evidenced by: Based on children's records review it was revealed that C1 - C5 do not have signed copies of form LIC9224. This poses a potenial health and safety risk to the children in care.
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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:Leslie Lepori
LICENSING EVALUATOR NAME:Melinda Mohr
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
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