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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493000369
Report Date: 02/06/2025
Date Signed: 02/06/2025 04:41:17 PM

Document Has Been Signed on 02/06/2025 04:41 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 CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:R.L. STEVENS EXTENDED CHILD CAREFACILITY NUMBER:
493000369
ADMINISTRATOR/
DIRECTOR:
JASON RIGGSFACILITY TYPE:
840
ADDRESS:2345 GIFFEN AVENUETELEPHONE:
(707) 579-6267
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 112TOTAL ENROLLED CHILDREN: 35CENSUS: 29DATE:
02/06/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Michelle DominguezTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Amy Strother made an unannounced case management visit to the facility after receiving an Unusual Incident Report (UIR) from the facility on 01/27/25, regarding a student’s, Child 1 (C1’s), inappropriate behavior directed toward another student on 01/24/25. LPA met with Facility Representative and Director, Michelle Dominguez (D1).

During today’s visit, 29 students were being supervised by D1 and 4 staff, operating within the licensed capacity and ratio requirements. LPA interviewed D1 and one additional staff, who was present during the incident on 01/24/25, (S1).

Based on interviews conducted, staff are helping to mitigate C1’s inappropriate behavior by separating C1 from the student that C1 tends to display inappropriate behavior towards, directing C1 to move to another area of the classroom to engage in a specific activity, giving verbal reminders to C1, and speaking to C1's parent about the behaviors.

The facility is following their written policies, which state in summary that a written behavior notice is signed and copy given to students authorized representative, next a Level 1 notice is issued if behavior from behavior notice continues during the next three days with guidance from the Program Director. After Level 1, a Level 2 notice is issued which results in 2 days suspension and/or until a meeting with Program Director and Center Director is held with the students authorized representative. The final level is Level 3, which results in expulsion, after not being able to resolve the continued behavior, going through each level or if the behavior warrants going straight to a Level 3. LPA was directed to the Parent Handbook to review the Child Behavior Policy on Extended Child Care's website. Based on interviews and record review the facility is following the Child Behavior Policy with C1.

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SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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 CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: R.L. STEVENS EXTENDED CHILD CARE
FACILITY NUMBER: 493000369
VISIT DATE: 02/06/2025
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There were no Title 22 deficiencies cited during today's inspection.

This report was reviewed and discussed with Facility Representative, Michelle Dominguez. Appeal Rights were provided.

Notice of Site Visit shall be posted for 30 days from today's visit. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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