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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009957
Report Date: 08/18/2021
Date Signed: 08/18/2021 06:27:14 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTER-S/AFACILITY NUMBER:
493009957
ADMINISTRATOR:BOEHM, JEANETTEFACILITY TYPE:
840
ADDRESS:530 NORTH CLOVERDALE BLVDTELEPHONE:
(707) 894-6037
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY:9CENSUS: 6DATE:
08/18/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Jeanette BoehmTIME COMPLETED:
06:45 PM
NARRATIVE
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An unannounced Plan of Correction Visit was conducted by Licensing Program Analyst (LPA) Amy Strother. The purpose of the visit was to review the status of the Plan Of Correction requested during a complaint investigation inspection that led to a Case Management - Defienciey report on 08/03/21.

During the visit on 08/03/21 Licensee, Jeanette Boehm (L1) was cited for combining the school-age children indoors with the preschool children and toddler children. During the visit, L1 stated that the School Age children were inside of the Preschool because she needed to answer the phone. The Licensee's Plan of Correction for the deficiency was to bring a phone into the school age room.

When LPA Strother arrived at the facility for today's POC inspection, L1 was not present at the facility. LPA went out to the School Age playground and observed 21 children in care with one teacher, Staff 1 (S1) and one aide, Staff 2 (S2). During an interview with staff, it was stated that 3 of the 21 children outdoors were school age children and the remaining children were preschoolers. During the interview, staff stated that the school age, preschool and toddler children have been combined outside and the school age and preschool children combined inside since LPA's last visit on 08/04/21.

Based on the above interview with staff, the Plan of Correction due by 08/04/21 has not been met. Civil Penalties were assessed for Failure to Correct. See LIC421FC.

Based on LPA's observations during today's visit, School Age children in care were observed to be combined with Preschool children outdoors, the following violation of the California Code of Regulations, Title 22; Division 12, were cited: see LIC 809-D. Appeal Rights were provided.


SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTER-S/A
FACILITY NUMBER: 493009957
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/19/2021
Section Cited

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101538.2 Outdoor Activity Space for School-Age Children (b) In combination programs, outdoor activity space provided for school-age child care center children shall be physically separated from space provided for other child care center children.
This requirement was not met as evidenced by:
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Based on LPA's observation and staff interview, school age children were combined in care with preschool children on the School age playground.
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L1 stated that she will be the teacher in the School age room. L1 stated that the preschool children will use the playground designated for the preschool children beginning 08/19/21. L1 stated that if the school age room does not have a qualified teacher available then the program will be closed until a teacher is hired.

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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 HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2021
LIC809 (FAS) - (06/04)
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