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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010190
Report Date: 10/28/2024
Date Signed: 10/28/2024 10:43:56 AM

Document Has Been Signed on 10/28/2024 10:43 AM - 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:YWCA PRESCHOOL-SEBASTOPOLFACILITY NUMBER:
493010190
ADMINISTRATOR/
DIRECTOR:		RIVAS NINO, NATHALIEFACILITY TYPE:
850
ADDRESS:466 JOHNSON STREETTELEPHONE:
(707) 829-2160
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: 11DATE:
10/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Director Cheryl MooreTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
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An unannounced case management visit was made by Licensing Program Analyst (LPA) Selena Mariani to follow up on an Unusual Incident Report (UIR) submitted by the facility on 10/17/24. The LPA met with the Director, Cheryl Moore today to discuss the incident. The facility reported that on 10/16/24, child C1 went outside without staff supervision while at the facility. During today's visit, the LPA conducted parent, staff interview and made observations inside the classroom and outside.

Due to insufficient information available at this time, a follow up visit will be conducted at a later date. This report was read and reviewed with the Director Cheryl Moore. There were no Title 22 deficiencies cited during this visit. The Notice of Site Visit shall be posted for 30 days.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Selena Mariani
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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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