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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010121
Report Date: 11/16/2023
Date Signed: 11/16/2023 02:54:36 PM

Document Has Been Signed on 11/16/2023 02:54 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:HEAD START - COUCH INFANT/TODDLERFACILITY NUMBER:
483010121
ADMINISTRATOR:WINSTON, RHONDAFACILITY TYPE:
830
ADDRESS:579 COUCH STREETTELEPHONE:
(707) 252-8931
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 9DATE:
11/16/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Thanh NguyenTIME COMPLETED:
03:00 PM
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A required inspection was made to the facility by Licensing Program Analyst (LPA), Glenn Ouye. LPA met with facility representative, Program Director, Thanh Nguyen. 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.

The facility’s operating hours are 8:00am – 4:00pm, Monday – Friday. The infant/toddler program uses two of the six classrooms. The facility was toured inside and outside, and the floor and yard plan submitted by the licensee were verified. Sign in/out records were reviewed. Items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children located (on high shelves out of reach of children.) There were no poisons observed during this inspection. LPA observed the toys, floors, desks and other equipment and surfaces are clean, toxic free, safe, and in good condition. There is uncontaminated drinking water available to children indoors and outdoors by use. The children's bathrooms are in safe and sanitary condition.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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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: HEAD START - COUCH INFANT/TODDLER
FACILITY NUMBER: 483010121
VISIT DATE: 11/16/2023
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There are functioning carbon monoxide detector and fire extinguishers which are fully charged in each classroom. The smoke detectors are hard wired and were unable to be tested during today's inspection. LPA reviewed documentation from the Vallejo Fire Department during the last inspection visit on February 2, 2023 which is an annual fire alarm maintenance. LPA observed the playground equipment and surface areas were in safe condition.

There is artificial turf with cushioning under the climbing structure to absorb falls. There were no bodies of water observed on the site..

During today's inspection, staffing ratios were being met, a total of 9 infants and toddlers being supervised by five staff. The facility was operating within the licensed capacity and ratio requirements. The requirement that one staff member present during the inspection possessed current CPR and First Aid certifications which is valid through November 14, 2025.

Five children’s records were reviewed at 1:15pm and contained complete and current information as required. Five staff files were reviewed and contained all records as required.

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. 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).

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HEAD START - COUCH INFANT/TODDLER
FACILITY NUMBER: 483010121
VISIT DATE: 11/16/2023
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of “medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. 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 are available at: https://www.ada.gov/resources/child-care-centers/.

Licensee [or facility representative] 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.

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 inquiries 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.

A notice of site visit was given to the Program Director, Thanh Nguyen and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the Director, Thanh Nguyen.

There were no Title 22 deficiencies cited during today's inspection.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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