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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010190
Report Date: 06/05/2025
Date Signed: 06/05/2025 05:17:36 PM

Document Has Been Signed on 06/05/2025 05:17 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: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: 15DATE:
06/05/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:37 AM
MET WITH:Laurin JohnsonTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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An unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Selena Mariani in response to a self reported, lack of supervision incident involving a child C1 and met with Site Supervisor (SS) Laurin Johnson and Assistant Director (AD) Nathalie Rivas Nino to discuss the incident.

On 05/08/25, it was reported via written unusual incident report (UIR) by AD that on 05/06/25 during the transition from the outside play yard to eat lunch inside C1 remained outside unsupervised. LPA conducted interviews with SS, AD, 3 staff (S1-S3) and attempted interviews with parent (P1) and child (C1).

AD, S1-S3 stated, on 5/6/25, the teachers and children transitioned from outside to inside the classroom to eat lunch and the door was closed. C1 opened the door to come inside smiling. C1 was outside unsupervised in the enclosed play yard for approximately 1- 3 minutes. AD informed C1's parent by phone, called the UIR into the Department and submitted a written UIR within 7 days. AD and S1-S3 had a meeting to go over transitions and active supervision on 5/7/25.

Based on available information, it has been determined that adequate supervision was not provided to child C1 during the incident on 05/06/2025.

Additionally, LPA review staff records and S1 missing immunization record and S3 missing was health screening and TB test results. LPA also observed the play yard sandbox had rotten and splintering wood and sandbox storage unit has sharp edges on roof and painted wood pieces flaking off the back.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Selena Mariani
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/05/2025 05:17 PM - It Cannot Be Edited


Created By: Selena Mariani On 06/05/2025 at 03:34 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: YWCA PRESCHOOL-SEBASTOPOL
FACILITY NUMBER: 493010190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2025
Section Cited
CCR
101230(c)(1)

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Care and Supervision. No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections
101216.2(e)(1) and 101230(c)(1). Supervision
shall include visual observation.
This requirement was not met as evidenced by:
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The Assistant Director stated that the center will be conducting a training for all staff in order to provide additional training on
active supervision and stated that she will email a summary of the training along with proof of attendance to the
LPA at selena.mariani@dss.ca.gov by 06/26/25.
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Based on interviews conducted by the LPA with AD, S1-S3 child C1 was without supervision of a teacher for approximately 1-3 minute in the play yard before C1 opened the classroom door to be reunited with their class. This presents a potential threat to the health and safety of children in care.
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Type B
06/26/2025
Section Cited
CCR101216(g)(1)

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(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
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Asst. Director stated she will make sure S3 provide completed health screening and TB test results and will email a copy of health screening and TB results to LPA Selena.Mariani@dss.ca.gov
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Based on record review, the licenee did not comply with the section cited above in which staff (S3) did not have a Health Screening LIC503 and TB test results, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Selena Mariani
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2025 05:17 PM - It Cannot Be Edited


Created By: Selena Mariani On 06/05/2025 at 03:50 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: YWCA PRESCHOOL-SEBASTOPOL
FACILITY NUMBER: 493010190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2025
Section Cited
HSC
1596.7995(a)(1)

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(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
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Asst.Director stated she will obtain all immunization records from S1, place in S1's file and email a copy to LPA Selena.Mariani@dss.ca.gov by 6/26/25
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Based on record review, the licensee did not comply with the section cited above in which S1 does not have proof of immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
06/26/2025
Section Cited
CCR101238.2(d)(1)

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(d) The surface of the outdoor activity space shall be maintained: (1) In a safe condition for the activities planned.

This requirement was not met as evidenced by:
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Assistant Director stated that she will work with Center Director and the Chief of Financial Officer to take action on repairing or replacing the equipement in disrepair and submit proof that the equipment is in safe condition by email to LPA at Selena. Mariani@dss.ca.gov by 06/26/25.
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Based on LPA observation the play yard sandbox has rotten and splintering wood and sandbox storage unit has sharp edges on roof and painted wood pieces flaking off the back, which poses a potential health, safety and/or personal rights risk(s) to children in care.
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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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Selena Mariani
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


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: YWCA PRESCHOOL-SEBASTOPOL
FACILITY NUMBER: 493010190
VISIT DATE: 06/05/2025
NARRATIVE
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Continue from LIC809

The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. Civil penalties are assessed on form LIC421FC for repeat violations within 12 months, an immediate $250 is being assessed today.

This report was read and reviewed with the Assistant Director Nathalie Rivas Nino. Notice of site visit shall be posted for 30 days. Appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Selena Mariani
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC809 (FAS) - (06/04)
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