Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493005994
Report Date: 03/14/2016
Date Signed: 03/14/2016 03:46:34 PM

COMPREHENSIVE INSPECTION
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:WILLOW TREE SCHOOL - PRESCHOOLFACILITY NUMBER:
493005994
ADMINISTRATOR:INEZ DUVALLFACILITY TYPE:
850
ADDRESS:137 PAYRAN STREETTELEPHONE:
(707) 763-2546
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:22CENSUS: 6DATE:
03/14/2016
TYPE OF VISIT:Required - 5 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Cherie StillTIME COMPLETED:
03:15 PM
NARRATIVE
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LPA Vickie Capurso-Valles conducted an unannounced 5 year inspection and met with teacher Barbara Pappas, initially. Director Cherie Still was not on site; she was in her home next door and came in later. Present were 1 teacher with 3 napping children in one room, and 3 children reading in one room. Children napping were not in visual supervision. All staff were fingerprint cleared. The building and both play yards were inspected. Hours are M-F, 7am-6pm.

No bodies of water on preschool site.
No weapons or firearms. There are no poisons 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 inside and outside with cups.
All food and beverages stored in fridges of 45' or less.
Menus were posted 1 week in advance. Center serves am and pm snack; children bring lunches.
There was not 1 or more working carbon monoxide detectors.
Playground equipment appeared in good and safe condition. Outdoor activity space surface appeared safe and free of hazards.
Staff records were reviewed for educational requirements and were complete. Staff had current CPR/First Aid.
Children's records reviewed for admission agreements and were complete.
Sign in/out sheets had full parent/guardian signatures.
The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. Notice of Site visit posted.

Upon receipt, licensee shall post report for 30 days, and provide copies of this licensing report to parents/guardians of children in care at the facility, and to parents/guardians of children newly enrolled at the facility during the next 12 months. Licensee shall provide the copies to parents no later than the next business day or the next day the child is in care and use form LIC9224 for parents/guardians to sign, confirming report was received. LIC9224 is to be kept in each child's file.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Victoria Capurso-VallesTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2016
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: WILLOW TREE SCHOOL - PRESCHOOL
FACILITY NUMBER: 493005994
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2016
Section Cited
H&S1596.954
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Carbon Monoxide Dectectors: Every licensed child day care center shall have one or more carbon monoxide detectors in the facility. Today, there was not 1 or more carbon monoxide dectectors on site.
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The licensee did not have one on site because she states the Fire Dept. said she did not need one because there is no gas line to this facility. The licensee will install by 3/15/16.
Type A
03/15/2016
Section Cited
101229(a)(1)
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Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time... . Today at visit, there were 3 napping children in a room, alone, with the door closed. The only staff on site was 1 teacher who was 2 rooms away with 3 children who were reading.
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Licensee states a baby monitor was in use in the nap room, and she had just stepped out to use the bathroom in her house adjacent to the preschool. Two other teachers were on break, and from now on breaks will be staggered.
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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: Victoria Capurso-VallesTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2016
LIC809 (FAS) - (06/04)
Page: 2 of 2