Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493000608
Report Date: 01/28/2019
Date Signed: 01/28/2019 01:09:14 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:HEAD START - PETALUMAFACILITY NUMBER:
493000608
ADMINISTRATOR:SUSILO, WARTINIGSHIFACILITY TYPE:
850
ADDRESS:110 ELLIS STREETTELEPHONE:
(707) 778-3896
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:20CENSUS: 16DATE:
01/28/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Ning WartiningsihTIME COMPLETED:
01:20 PM
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An inspection was made to the facility by Licensing Program Analyst (LPA), Jennifer Velasco. 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. Personnel are fingerprinted and associated to the Head Start- Lincoln Center site # 490111008. This program is operated by Head Start and is a Title 5 funded program. LPA met with director Ning Wartiningsih (Director).

The facility’s operating hours are 8:00 AM - 2:15 PM, Monday-Friday, from August through the end of June. The facility is open on some but not all Fridays to provide care to children. The facility was toured inside and outside and the floor and yard plan submitted by the licensee were verified. Items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children in a key locked cupboard. Director stated there are no poisons, and none were observed. The toys, floors, desks and other equipment and surfaces are clean, toxic free, safe, and in good condition. There is uncontaminated drinking water available to children both indoors and outdoors. The children's bathrooms are in operational, safe, and sanitary condition. Food prep areas are clean. Food is properly stored and refrigerated as needed. There was no contaminated food observed. Garbage cans containing solid waste have tight fitting lids. LPA observed a working carbon monoxide detector and fire alarm system in the facility. The playground was fully fenced and free of hazards. The playground equipment and surface areas were in safe condition. There is wood chip cushioning underneath climbing structures and/or play equipment to absorb falls. There were no bodies of water observed. Director stated no weapons are stored on site and none were observed. During today's inspection, licensing staffing ratios were being met, and 16 children were being supervised by four 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 with an expiration date in 08/2019. The sign-in/sign-out procedure was reviewed and was in compliance. Ten children’s records were reviewed at 12:20PAM, and contained signed admission agreements and Parents' Rights forms. Three staff records were reviewed at 12:40 PM and contained documentation of education and training as required.

Continued on LIC 809-C

SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2019
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: HEAD START - PETALUMA
FACILITY NUMBER: 493000608
VISIT DATE: 01/28/2019
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This facility is currently providing Incidental Medical Services (IMS) to one child with a g-tube. There is a nurse (employed by the school district) who provides g-tube management. The Department’s IMS policy was discussed with Director. Facility has IMS documentation in Plan of Operation as required. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.

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: www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices brochure, were reviewed and discussed with Licensee. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2019
LIC809 (FAS) - (06/04)
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