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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009958
Report Date: 08/18/2021
Date Signed: 08/18/2021 06:34:50 PM

Document Has Been Signed on 08/18/2021 06:34 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTERFACILITY NUMBER:
493009958
ADMINISTRATOR:BOEHM, JEANETTEFACILITY TYPE:
850
ADDRESS:530 NORTH CLOVERDALE BLVDTELEPHONE:
(707) 894-6037
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 21DATE:
08/18/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Jeanette BoehmTIME COMPLETED:
06:45 PM
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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 Corrections requested during a complaint investigation inspection on 08/03/21 and 08/04/21.

During the visit on 08/03/21 Licensee, Jeanette Boehm (L1) was cited a Type B deficiency for failing to have two individuals criminal record clearances associated to the facility. Based on staff interviews and record review A1 and S6 were working and not associated to the facility and a transfer request was not completed. L1's plan of correction stated that A1 was associated to the facility on 05/04/21 and S6 although not currently working at the facility will be associated prior to returning to work for the facility. During today's inspection all individuals requiring Criminal Record Clearances were cleared and associated. The plan of correction has been met, and the deficiency cleared.

A second Type B deficiency was cited on 08/03/21 based on a failure to meet the appropriate staffing to children ratios. Staff interviews stated that the preschool has had more than 15 children, and up to 20 children in care on more than one occasion with one qualified teacher and 1 or two aides that do not hold units in Early Childhood Education. L1's plan of correction stated that she is hiring new staff and will have two teachers in each classroom and one aide, providing incentives to the aides to obtain 6 units in ECE, by utilizing the R&R and paying for any remaining costs. 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). The 21 children present were both School Age and Preschool age children. When L1 arrived to the facility at approximately 10:35am, L1 took 6 school-age children to the preschool room to gather their personal items and escorted the 6 children to the school age classroom, bringing the preschool into ratio compliance, with 1 fully qualified teacher and an aide with 15 preschool children. The Plan of Correction has not been met. A Civil Penalty has been accessed. See LIC421FC.
Continue on LIC809-C
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
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)
Page: 1 of 4
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
FACILITY NUMBER: 493009958
VISIT DATE: 08/18/2021
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A third Type B deficiency was cited on 08/03/21 based on interviews with L1 and S1-S3 and S5-S6, the hot water heater in the school age room has an issue that causes the sink water to smell like rotten eggs, and the preschool children use the school age bathroom sink when playing outside to wash their hands. L1's Plan of Correction stated that on 04/21/21 the hot water was disconnected and the water no longer smells of rotten eggs. During the inspection on 08/03/21 LPA confirmed that the water had no odor. LPA also confirmed during today's inspection that no odor was present while the water was running from the sink. The Plan of Correction has been met and the deficiency cleared.

During the visit on 08/04/21 Licensee, Jeanette Boehm (L1) was cited a Type B deficiency for failing to communicate with children's authorized representatives when minor injuries occurred. L1's plan of correction stated that beginning 08/04/21 L1 and staff would begin to use the BrightWheel application to communicate any injuries to the children's authorized representatives. L1 provide proof that on 08/04/21 and 08/11/21 the BrightWheel application was used to communicate minor injuries to children of preschool children. LPA determined that the use of the application meets to plan of correction and the deficiency is cleared.

A second Type B deficiency was cited on 08/04/21 based on staff interviews milk is only served to the children if they request it and a milk alternative is not served to children with milk allergies. L1's Plan of Correction stated she will remind staff on 08/05/21 that milk needs to be served to all children, not just the children that request it, and cover this topic during the staff meeting on 08/29/21. L1 stated that she will purchase a milk alternative such as almond milk for children with milk allergies, beginning 08/09/21. During today's inspection, LPA observed that all of the preschool children at the lunch table were provided with a cup of milk and a child with a milk allergy was served almond milk as an alternative. The plan of correction was observed to be met and the deficiency cleared during today's inspection.

A third Type B deficiency was cited on 08/04/21 based on staff interviews stating that menus were not posted prior to April 2021. L1's Plan of Correction stated that she has a menu that rotates every week, and will start to write the date on the menu each week and hand write in any changes made to the menu as needed then file weekly. L1 stated that she will post the menu in the kitchen and add a copy to the hallway postings. During today's inspection LPA did not observe any menus posted in the hallway. LPA observed a menu posted on the kitchen refrigerator dated "Week of Aug, 2, 2021". The Plan of Correction has not been met, Civil Penalties were accessed for Failure to Correct. See LIC421FC.
Continue on LIC809-C page 2
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
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
LIC809 (FAS) - (06/04)
Page: 2 of 4
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
FACILITY NUMBER: 493009958
VISIT DATE: 08/18/2021
NARRATIVE
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A Type A deficiency was cited on 08/04/21 based on staff interviews stating that on more than one occasion rusty nails and screws were found by children on the playground after it was brought to L1’s attention. L1's Plan of Correction stated that on 04/22/21 L1 had her husband bring in a large magnetic roller to pick up any metal objects from the play yards. L1 stated that no nails or screws have been found since. L1 stated the yard is scanned daily for safety. During today's inspection LPA toured the playground being used by the children in care, which was the yard labeled as the School Age Play Yard on the LIC999 Facility Sketch. LPA did not observe any rusty nails or screws on the playground during today's inspection. The deficiency has been cleared. LPA advised L1 to continue to monitor the playground for safety prior to use by children. LPA attempted to verify that the Parents/guardians had signed a form LIC9224 for each child's file. L1 provided LPA with 13 signed LIC9224 forms. Eleven of the 13 LIC9224 forms were for children present during today's inspection. LIC9224 forms were not available for 10 children present (Child 1 - Child 10) in the preschool or toddler rooms.

The following violation of the California Code of Regulations, Title 22; Division 12, were cited: see LIC 809-D. Appeal Rights were provided.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
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
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/18/2021 06:34 PM - It Cannot Be Edited


Created By: Amy Strother On 08/18/2021 at 04:17 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTER
FACILITY NUMBER: 493009958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2021
Section Cited
HSC
1596.8595(c)(1)

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(c)(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b.
This requirement has not been met as evidenced by:
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L1 stated the she will submit signed LIC9224 forms for C1-C10 via photos emailed to amy.strother@dss.ca.gov by 08/20/21.
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Based on file review, Child 1 - Child 10 (C1-C10) files did not contain a signed form LIC9224 required after receiving a Type A citation on 08/04/21.
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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: 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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