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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283010138
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:32:28 PM

Document Has Been Signed on 12/04/2024 03:32 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: 15CENSUS: 9DATE:
12/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:46 PM
MET WITH:Tamara KinmanTIME VISIT/
INSPECTION COMPLETED:
03:35 PM
NARRATIVE
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During the course of a complaint investigation, an additional deficiency was identified. During LPAs record review it was revealed that the sign in/out procedure was incomplete. Ten children did not have a sign in/out sheet with the full legal signature of the person's signing the child in/out as required.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

Exit interview conducted and report was reviewed with Director, Tamara Kinman.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
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 12/04/2024 03:32 PM - It Cannot Be Edited


Created By: Melinda Mohr On 12/04/2024 at 02:49 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HOPPER CREEK MONTESSORI
FACILITY NUMBER: 283010138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2024
Section Cited
CCR
101229.1(a)(1)

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(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain, and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.
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Director stated she will send out an email immediately notifying parents to sign their children in /out using their full legal signature. Director also stated they will stand by the binder reminding parents to sign their children in and out.
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This was not met as evidenced by:
During LPA's review of the children's sign in/out procedures, it was revealed they were incomplete, missing the full legal signature of the persons signing the child in/out.The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
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Director will email LPA copies of the sign in/out sheets with the full legal signatures of the person signing the child in/out to Melinda.mohr@dss.ca.gov

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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: 12/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2024


LIC809 (FAS) - (06/04)
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