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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110708
Report Date: 01/31/2024
Date Signed: 01/31/2024 03:41:53 PM

Document Has Been Signed on 01/31/2024 03:41 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:BETHLEHEM CHILDRENS CENTER-INFANTFACILITY NUMBER:
490110708
ADMINISTRATOR:MC NALLY, DEBORAHFACILITY TYPE:
830
ADDRESS:1300 ST. FRANCIS RD.TELEPHONE:
(707) 538-2266
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
01/31/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:06 AM
MET WITH:Linda StaudenmayerTIME COMPLETED:
03:51 PM
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A required annual inspection of the facility was conducted by Licensing Program Analyst (LPA) Robert Maciel, who met with Facility Representative Linda Staudenmayer. The facility file was reviewed prior to this inspection. A review of the personnel report on file indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee 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 7:30 AM - 4:30 PM, Monday-Friday. The facility was toured inside and outside and the floor and yard plan submitted by the licensee were verified. The sign-in/sign-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. Facility Representative stated poisons are not stored on site and none were observed by LPA. 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 of water bottles. The children's bathrooms are in safe and sanitary condition. Facility Representative stated that children provide lunch from home and the facility provides snacks. Food prep areas are clean. Food is properly stored and refrigerated as needed. There was no contaminated food observed. Garbage cans containing solid waste have tight fitting lids. LPA observed a working carbon monoxide detector, smoke alarm, and fire extinguisher rated at least 2A10BC in the facility. LPA observed that infant sleep logs were not complete.
Continued on LIC809-C
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2024
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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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: BETHLEHEM CHILDRENS CENTER-INFANT
FACILITY NUMBER: 490110708
VISIT DATE: 01/31/2024
NARRATIVE
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The playground equipment and surface areas are in safe condition. There is wood chip and rubber cushioning underneath climbing structures and/or play equipment to absorb falls. There were no bodies of water observed on the site. Director stated no weapons are stored on site, and none were observed. During today's inspection, staffing ratios were being met, and 7 children were supervised by 3 staff. The facility was operating within the licensed capacity and ratio requirements. At least one staff member present during the inspection possessed current CPR and First Aid certifications, which expire in 08/2025. Three staff records were reviewed at 12:23 PM and which revealed that staff 3 (S3) did not possess a complete health screening and staff 1 (S1) did not possess a complete Personnel Report. Five children’s records were reviewed at 1:22 PM which revealed that child 1 (C1) and child 4 (C4) did not possess complete Individual Infant Sleepling Plans.

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.

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 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.

Continued on LIC 809C
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BETHLEHEM CHILDRENS CENTER-INFANT
FACILITY NUMBER: 490110708
VISIT DATE: 01/31/2024
NARRATIVE
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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.

The following violations of the California Code of Regulation, Title 22, Division 12, were cited: see LIC809-D. Appeal Rights were provided. Exit interview conducted and report was reviewed with the Facility Representative Linda Staudenmayer. A notice of site visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 01/31/2024 03:41 PM - It Cannot Be Edited


Created By: Robert Maciel On 01/31/2024 at 02:16 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: BETHLEHEM CHILDRENS CENTER-INFANT
FACILITY NUMBER: 490110708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(1) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, staff 3 (S3) did not possess a complete LIC 503 Health Screening which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Facility representative stated that she would ensure S3 completes their LIC503 and will send a copy of the form to LPA by email at robert.maciel@dss.ca.gov.
Type B
Section Cited
CCR
101217(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, staff 1 (S1) did not possess a complete LIC501 Personnel Report which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Facility representative stated that she would ensure S1 completes their LIC501 and will send a copy of the form to LPA by email at robert.maciel@dss.ca.gov.
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: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2024 03:41 PM - It Cannot Be Edited


Created By: Robert Maciel On 01/31/2024 at 02:16 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: BETHLEHEM CHILDRENS CENTER-INFANT
FACILITY NUMBER: 490110708

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(b)(2)
Infant Needs and Services Plan
(b) The needs and services plan shall be in writing and shall include the following: (2) Infants up to 12 months of age shall have a completed Individual Infant Sleeping Plan [LIC 9227 (3/20)], which is incorporated by reference.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on record review, child 1 (C1) and child 4 (C4) did not possess complete Individual Infant Sleepling Plans which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Facility Representative stated she would ensure the Individual Infant Sleepling Plans are complete and send a copy of them to LPA by email at robert.maciel@dss.ca.gov
Type B
Section Cited
CCR
101429(a)(2)(C)
Responsibility for Providing Care and Supervision for Infants
(C) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, sleep logs for each infant in care were not complete which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Facility representative stated she would send a copy of one week of infant sleep logs to LPA by email at robert.maciel@dss.ca.gov.
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: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024


LIC809 (FAS) - (06/04)
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