Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490109272
Report Date: 03/08/2016
Date Signed: 03/08/2016 10:51:04 AM

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:4C'S PETALUMA CHILD DEVELOPMENT CENTERFACILITY NUMBER:
490109272
ADMINISTRATOR:DUSEK, LINDAFACILITY TYPE:
850
ADDRESS:401 S MC DOWELLTELEPHONE:
(707) 763-4990
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:54CENSUS: DATE:
03/08/2016
TYPE OF VISIT:Required - 5 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Tracy WilliamsTIME COMPLETED:
11:00 AM
NARRATIVE
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(3) LPA Kevin O'Connell conducted an unannounced Required 5-year inspection and met with Tracy Williams, Director. Present were 32 children, 5 teachers, one cook and the director. Staff ratio and capacity in compliance. Staff were fingerprint cleared and associated except for the director and lead teacher Maria Vencez who both transferred from the closed 4C's Healdsburg center last August. . All children were always under visual supervision. LPA inspected the one preschool classroom and the play yard. Hours: M-F 7:00-5:30, and open year round. On Wednesday afternoons 12:30 -3pm is preschool extended care.
No bodies of water, weapons, poisons, or firearms were on site.
Disinfectants, toxins and other hazards were inaccessible to children, in locked cabinets or up high.
Materials and surfaces appear safe and toxic free.
There are no medications stored on site at this time. IMS plan of operations discussed.
All toilets and handwashing facilities appeared safe and sanitary.
All floors appeared safe and clean.
Furniture and equipment appeared to be in good condition and safe.
All kitchen/food prep areas appeared clean and free of rodents.
Solid waste storage containers have lids.
Uncontaminated drinking water available with inside and outside with cups.
Breakfast, lunch and afternoon snack are served.
Playground equipment appeared in good and safe condition.
Outdoor activity space surface appeared safe and free of hazards.
Staff records were reviewed for health screenings and were complete.
Staff had current CPR/First Aid.
Children's records reviewed for Parent's Rights and PM286 Blue Immunization form and were complete.
Sign in/out sheets had full parent/guardian signatures.
Postings and menu were visible to public.
Notice of Site Visit shall be posted for 30 days from today's visit.
See LIC 809 D for citations, appeal rights given.
SUPERVISOR'S NAME: Linda WalkerTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2016
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: 4C'S PETALUMA CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 490109272
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2016
Section Cited
101170(e)(1)
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101170(e)(1) Criminal Record Clearance. Prior to working or volunteering in a licensed child care facility, all individuals subject to a criminal record review shall obtain a clearance or criminal record exemption.
Teacher Maria Vencez paper work was not processed last August when she transferred from 4C's Healdsburg (closed) and now needs
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Director states that she will get finger printed and provide a livescan receipt form to LPA by 3/9/16.

kevin.oconnell@dss.ca.gov
(707) 588-5099
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to be fingerprinted again as her criminal clearance does not show in the system. She was fingerprinted 18 years ago.
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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: Linda WalkerTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2016
LIC809 (FAS) - (06/04)
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