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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010442
Report Date: 10/07/2025
Date Signed: 10/07/2025 04:44:58 PM

Document Has Been Signed on 10/07/2025 04:44 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:HEAD START - CARITAS VILLAGEFACILITY NUMBER:
493010442
ADMINISTRATOR/
DIRECTOR:		LEVITIN, KENDRAFACILITY TYPE:
850
ADDRESS:301 6TH STREET, SUITE 123TELEPHONE:
(707) 546-5776
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 18TOTAL ENROLLED CHILDREN: 18CENSUS: 15DATE:
10/07/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Kendra LevitinTIME VISIT/
INSPECTION COMPLETED:
04:59 PM
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Licensing Program Analyst (LPA) Amy Strother made an unannounced case management visit to the facility after receiving an Unusual Incident Report (UIR) from the facility on 09/29/25, stating that children, C1 and C2 went home on 09/25/25 in unchanged diapers, specifically the same diapers they were wearing when dropped off at the center and developed a diaper rash. LPA met with facility representative, Center Director, Kendra Levitin (D1) to discuss the UIR.
D1 stated, as written in the UIR, that a plan for the children (C1 and C2) was created and that she met with her team about appropriate diaper policies and procedures. During today's visit, D1 stated that as a result of the 09/25/25 incident, she met with the parents of C1 and C2 and developed a plan to have a separate diaper changing log for children C1 and C2 (siblings), that staff will log diaper changes on, and provide a copy to C1 and C2's parents at the end of each day. D1 stated that they are writing the time of the diaper change on the log, and also writing the time of the diaper change and the number of each diaper change (first, second, etc.) in sharpie on the diaper. D1 stated that writing on the diaper shows the parent what time that diaper was placed on the child and how many changes occurred and they can compare it against the log.

LPAs review of attendance records document that C1 and C2 arrived to the facility at 9:15am and departed at 2:39pm on 09/25/25. LPA asked D1 if there was a list of children who are wearing diapers posted anywhere in the facility. D1 stated that there used to be a list, but it was taken down to be updated, and not replaced. D1 stated that on 09/25/25 there were four children in attendance that wear diapers C1-C4, D1 stated that diaper changes did occur on 09/25/25 for C3 and C4. LPA reviewed a binder of "diaper changing & toileting" logs, observing that C3 had a diaper change recorded at 9:05am on 09/25/25 and C4 had a diaper change recorded at 10:15am on 09/25/25.
Continue on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2025
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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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: HEAD START - CARITAS VILLAGE
FACILITY NUMBER: 493010442
VISIT DATE: 10/07/2025
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LPA did not observe any additional diaper changes recorded on 09/25/25. During today's interview with D1, D1 stated that she believes that C3 and C4 had additional diaper changes that were not recorded. D1 stated that she didn't feel that the logs were complete. LPA observed the current logs to be stored on a clipboard in the children's bathroom near the diaper changing table.

LPA interviewed 2 staff (S1&S2) who stated that they understand that diapers are to be changed every two hours and as needed, stating that D1 will ask them to change a diaper when she needs help with diapers. Both S1 and S2 confirmed that they had been informed of a diapering plan for C1 and C2 and that C1 and C2 have a specific log, and will provide copies of the log to C1 and C2's parents. S1 stated that she now helps with the responsibility of making sure that diapers get changed. S2 stated that D1 and S1 do the diaper changes, but she will let them know if she notices a diaper needs to be changed and understands about the logs if she does change a diaper.

Based on interviews conducted and a review of the UIR, C1 and C2 did not receive diaper changes while in care on 09/25/25. Based on the evidence obtained, the following violation of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

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

Exit interview conducted and report was reviewed with facility representative, Kendra Levitin.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2025 04:44 PM - It Cannot Be Edited


Created By: Amy Strother On 10/07/2025 at 03:56 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: HEAD START - CARITAS VILLAGE
FACILITY NUMBER: 493010442

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2025
Section Cited
CCR
101223(a)(2)

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101223 Personal Rights(a) The licensee shall ensure that each child is accorded the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement was not met as evidenced by:
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Director (D1) stated she will work with her Area Supervisor to develop a plan for all staff, including visiting staff filling in, to successfully follow a diaper changing routine, to include diaper change times, identification of children in diapers, logging protocals, including where log is stored and team responsibilities
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Based on record review and interview, on 09/25/25 children C1 and C2 did not have their diapers changed during a 5.5 hour care day, and logs for additional children C3 and C4 were not complete, which poses a potential Personal Rights & Health and Safety risk to children in care.
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and submit the plan to LPA Strother by 10/28/25. amy.strother@dss.ca.gov

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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:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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