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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493000369
Report Date: 04/17/2024
Date Signed: 04/17/2024 03:57:13 PM

Document Has Been Signed on 04/17/2024 03:57 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: 41CENSUS: 29DATE:
04/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:01 PM
MET WITH:Michelle Dominguez TIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA), Amy Strother made an unannounced case management visit to the facility to follow up on the facilities procedures to track students, specifically during transitions. Prior to today’s visit, LPA was included on an email dated 03/27/24 that was sent out to Extended Child Care facility Center Directors, to include Michelle Dominguez (D1), outlining a set of standardized procedures to track students. The email stated that the outlined procedures included in the email were effective immediately and would be finalized at the Center Director’s meeting scheduled for 04/04/24. LPA met with and interviewed D1 during today’s visit. D1 was able to verbally explain and outline the procedures for tracking students and give details of the role she and other staff have in the process of tracking. D1 was able to provide LPA with copies of the classroom tracking sheets used today and prior dates, (04/15/24 – 04/16/24). Additionally, LPA observed students being signed in through the HUBBE electronic system, names written and numbered on a white board in the classroom, and students names highlighted on the daily tracking sheet, following the outlined procedure from the 03/27/24 email. During today’s visit children were observed transitioning from the classroom by being excused from the tables by name to line up at the door and then counted on a handheld clicker by staff. Once outside the students lined up on the blacktop and were counted again using the clicker to confirm the total number of students were present. LPA then observed the group transition from outdoor time. Students were observed lining up on the blacktop, the staff counted students using the clicker to confirm that all students were present in the line, and then proceeded to walk toward the classroom. Some of the students entered the classroom and others made a stop to the bathrooms. Two staff were observed going inside and one staff stayed outside the bathrooms until bathroom needs were complete. Once all students were back to the classroom an additional head count was taken to confirm that all students were accounted for. As students were picked up by their authorized representative D1 crossed their name off the daily tracking sheet and removed them from the white board. D1, Staff 1, Staff 2 (S1-S2) and the 29 students present during today’s visit, demonstrated a clear understanding of the procedures in place to track students during transitions.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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 3
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: 04/17/2024
NARRATIVE
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During the visit LPA reviewed the employee roster, a list of individuals with criminal record clearances associated to the facility. LPA did not observe S1 or S2’s names on the list. LPA called the Community Care Licensing Regional office requesting that office staff complete a name search for S1 and S2. Based on a review of the Criminal Record Clearance website, Guardian, S1 and S2 do not have completed clearances and are not associated to the facility. LPA spoke to the Executive Director of Extended Child Care (D2) during the visit. D2 stated that clearance letters were received for S1 and S2 and therefore were cleared to work at the facility. Upon review of the clearance letters, D2 noted that they did not contain the correct facility number. LPA and D2 discussed procedures to ensure that staff have eligible clearances and associations prior to working in the licensed facility.

The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. Appeal Rights were provided. A civil penalty in the amount of $200 was accessed. See LIC421BG. Appeal Rights were provided.

LPA Strother informed facility representative, Michelle Dominguez that this report dated 04/17/24 document(s) one Type A citation. Type A citation(s) shall be posted for 30 consecutive days as there is an immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Strother informed the facility representative to provide a copy of this licensing report dated 04/17/24 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.

Exit interview conducted and report was reviewed with the facility representative, Michelle Dominguez.

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

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2024 03:57 PM - It Cannot Be Edited


Created By: Amy Strother On 04/17/2024 at 03:05 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: R.L. STEVENS EXTENDED CHILD CARE
FACILITY NUMBER: 493000369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/18/2024
Section Cited
CCR
101170(e)(1)

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 Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.

This requirement was not met as evidenced by:
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Director will have S1 and S2 redo the livescan clearance process and confirm they are associated to the facility prior to returning to work. D1 or D2 will submit a written procedure to LPA Strother by 04/18/24 at 5:00pm to include how Extended Child Care will confirm that the Livescan process was completed and each individual is associated to the facility prior to their first day of work.
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Today S1 and S2 were observed working in the facility. Based on record review, S1 and S2 do not have eligible clearances or an association to the facility. A civil penalty applies.
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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:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2024


LIC809 (FAS) - (06/04)
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