Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490109272
Report Date: 05/25/2016
Date Signed: 05/25/2016 06:04:04 PM

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: 26DATE:
05/25/2016
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Maria VencesTIME COMPLETED:
04:00 PM
NARRATIVE
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LPA Leticia Rosales-Meza & Kim Miller, Investigator conducted a case management on another matter. While visiting this facility the following deficiency was cited:


See LIC 809D for deficiency cited during this visit. Appeal Rights are given






NOTICE OF SITE VISIT POSTED AND MUST REMAIN POSTED FOR 30 DAYS
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Leticia RosalesTELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2016
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 2


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: 05/25/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/25/2016
Section Cited
101221(d)
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Child’s Records. The licensee shall ensure that there are separate, complete and current records kept for each child attending the child care center.

Today, upon request a child's record was not on site at the facilty and not available on a timely manner.
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A Human Resources staff brought child's records during the site visit.

Cleared
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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 HollonTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Leticia RosalesTELEPHONE: (707) 588-5061
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2016
LIC809 (FAS) - (06/04)
Page: 2 of 2