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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493000608
Report Date: 03/07/2022
Date Signed: 03/07/2022 01:37:04 PM


Document Has Been Signed on 03/07/2022 01:37 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:HEAD START - PETALUMAFACILITY NUMBER:
493000608
ADMINISTRATOR:SUSILO, WARTINIGSHIFACILITY TYPE:
850
ADDRESS:110 ELLIS STREETTELEPHONE:
(707) 778-3896
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:20CENSUS: 9DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lori Backer, Kendra LevitinTIME COMPLETED:
12:30 PM
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A required annual inspection of the facility was conducted by Licensing Program Analyst m,lsd;/.Jennifer Velasco (LPA). The facility file was reviewed prior to this inspection. A review of the personnel report on file indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA met with Area Supervisor Lori Backer (M1) and Center Director Kendra Levitin (D1), who were reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. This program is operated by Community Action Partnership of Sonoma County on the campus of McKinley Elementary School. The facility’s operating hours are 8:00 a.m. - 2:45 p.m., Monday-Thursday, from August through the end of the school year in June. The facility is closed on Fridays. The facility was toured inside and outside, and the floor and yard plan submitted by the licensee were verified. Sign in/out records were reviewed and in compliance. The items which could pose a danger to children (such as detergents, cleaning compounds and medications) were inaccessible to children in the janitor's closet, secured by a key locked door. D1 stated there are no poisons in the facility, and none were observed during this inspection. The toys, floors, desks and other equipment and surfaces are clean, toxic free, safe, and in good condition. There is drinking water available to children both indoors and outdoors by use of water bottles and cups used both indoors and outdoors. The children's bathrooms are in safe and sanitary condition. The Center’s isolation area for any child who becomes ill while in care is located in the facility office. A secondary isolation area is in the room next to the office. Facility serves breakfast and lunch. LPA observed a posted menu. Food prep areas were observed to be clean. Food was observed to be properly stored and refrigerated as needed. There was no contaminated food observed. Garbage cans containing solid waste have tight fitting lids.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HEAD START - PETALUMA
FACILITY NUMBER: 493000608
VISIT DATE: 03/07/2022
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LPA observed a working carbon monoxide detector in the facility. The playground equipment and surface areas were in safe condition. There is sufficient wood chip cushioning underneath climbing structures and/or play equipment to absorb falls. The facility has a waiver on file with the Department; the waiver allows the facility to use the kindergarten playground when it is not in use by kindergarteners. There were no bodies of water observed on the site. Director stated no weapons are stored on site, and none were observed. During today's inspection, staffing ratios were being met, and nine children were being supervised by three staff. The facility was operating within the licensed capacity and ratio requirements. At least one staff member present during the inspection possessed current CPR and First Aid certifications, which expire in 08/2023. Nine children’s records were reviewed at 10:30 a.m. and contained signed admission agreements and immunization records or medical exemptions as required. Four staff records were reviewed at 11:00 a.m. and contained documentation of education and training as required. Incidental Medical Services (IMS) policy was discussed. The facility has an IMS plan on file with the Department. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. There were no Title 22 deficiencies cited during today's inspection. Exit interview was conducted and report was reviewed with D1. To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC809 (FAS) - (06/04)
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