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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483001828
Report Date: 10/04/2023
Date Signed: 10/04/2023 04:34:42 PM


Document Has Been Signed on 10/04/2023 04:34 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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
483001828
ADMINISTRATOR:HAYMER, MORNENFACILITY TYPE:
850
ADDRESS:581 PEABODY ROADTELEPHONE:
(707) 447-7685
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:75CENSUS: 27DATE:
10/04/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:BrendaTIME COMPLETED:
04:50 PM
NARRATIVE
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During the course of a complaint investigation, Licensing Program Analyst (LPA), Melchisedeck Augustin made an unannounced Case Management (CM) visit and met with the Center Director (CD), Brenda Hardaway, to deliver a several citations for a deficiencies that were observed. LPA interview CD, one staff (S3) and two adults (A2 & A3) which confirmed that an adult (A1) without criminal record clearance worked and provided care and supervision to the children in the Discovery Preschool classroom for more than five days in the month of July 2023. Furthermore, CD submitted time sheet for A1 which corroborated A1 was previously employed at the facility and worked more than five days, and the facility with not comply with requirements of Criminal Record Clearance of California Code of Regulations (CCR) 101170(e)(1), and as such, an immediate $500 Civil Penalty was assessed because CD did not ensure A1 obtained a criminal record clearance prior to working at the facility. Additionally, Department records indicated A1 did not obtain an approved criminal record clearance.

LPA reviewed five staff (S1-S5) records at 1:54pm which revealed S1 through S5's records were either incomplete and/or did not contain one of the following item(s): required staff Immunization Record (IR), evidence of negative TB clearance, Health Screening (LIC 503), second page of Personnel Record (LIC 501) was not signed, and/or AB 1207 Mandated Reporter Training certificate.

Facility representative 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. (Continue to LIC 809-C)
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 10/04/2023 04:34 PM - It Cannot Be Edited

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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 483001828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/05/2023
Section Cited
CCR
101170(e)(1)

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Obtain a California clearance or a criminal record exemption as required by the Department.

This requirement is not as evidenced by: Based on Department records and interviews conducted with CD, S3, A2 & A3 which confirmed an adult without criminal record
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Center Director (CD) stated A1 was no longer employed at the facility. CD agreed to produce a written statement reflecting she understood that all staff were required to obtained a criminal record clearance prior to working at the facility, and how she would ensure violation of CCR 101170 did not re-occur.
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clearance worked in DP classroom for more than five days in the month of July 2023, and as such, an immediate CP of $500 was assessed. This posed an immediately health, safety and/or personal rights risk to the children in care.
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CD intends to submit her POC to the Department by 10/05/23 via email or fax.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099

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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 LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 483001828
VISIT DATE: 10/04/2023
NARRATIVE
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Exit interview conducted and report was reviewed with Center Director, Brenda Hardaway. 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. The following violations of the California Code of Regulations, Title 22; Division 12, were observed during today’s visit. Appeal Rights were provided.

LPA Melchisedeck Augustin informed Facility representative, Brenda Hardaway that this report dated 10/04/2023 document(s) one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Melchisedeck Augustin informed the Facility representative to provide a copy of this licensing report dated 10/04/2023 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/04/2023 04:34 PM - It Cannot Be Edited

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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 483001828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2023
Section Cited
CCR
101216(g)(1)

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Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.
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Center Director (CD) stated she already requested evidence of negative TB clearance and completed Health Screening (LIC 503) for all staff that are missing their evidence, and once CD obtained evidence from staff, she would submit staff's evidence of negative TB
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This requirement was not met as evidenced by: Based on five staff (S1-S5) records reviewed at 1:54pm which revealed S2-S3 & S5's records did not contain evidence of negative TB clearance. This poses/posed a potential health, safety and/or personal rights risk to the children in care.
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clearance to the Department by 10/14/23 via mail, email or fax.

Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
Type B
11/18/2023
Section Cited
HSC1596.8662(b)(1)

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
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Center Director (CD) stated she would ensure all staff that did not have the training would complete the online training module at mandatedreporterca.com and CD intends to submit staff's current certificates to the Department by 11/18/23 via mail, email or fax.
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This requirement is not met as evidenced by: Based on five staff (S1-S5) records reviewed at 1:54pm which revealed S2-S4's records were missing AB 1207 Mandated Reporter Training certificates. This posed a potential health, safety and/or personal rights risk to children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5099
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 LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/04/2023 04:34 PM - It Cannot Be Edited

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: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 483001828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2023
Section Cited
HSC
1596.7995(a)(1)

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Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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Center Director (CD) stated she would ensure S1-S5, along with all other preschool staff, obtained evidence of their required staff immunization records, and CD intends to submit evidence of required immunization records for S1-S5 by 10/14/23 via mail, email or fax.
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This requirement was not met as evidenced by: Based on five staff (S1-S5) records reviewed at 1:54pm which revealed S1-S5's records did not contain required staff immunization records. This poses a potential health, safety and/or personal rights risk to the children in care.
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Email: melchisedeck.augustin@dss.ca.gov
Fax: 707-588-5088

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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 LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:
DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/04/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5