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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233009794
Report Date: 09/12/2024
Date Signed: 09/12/2024 02:03:54 PM

Document Has Been Signed on 09/12/2024 02:03 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BOONT TRIBE COMMUNITY SCHOOL P/SFACILITY NUMBER:
233009794
ADMINISTRATOR/
DIRECTOR:		SEASHA ROBBFACILITY TYPE:
850
ADDRESS:8300 HIGHWAY 128TELEPHONE:
(707) 895-3590
CITY:PHILOSTATE: CAZIP CODE:
95466
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 0DATE:
09/12/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:12 PM
MET WITH:Seasha RobbTIME VISIT/
INSPECTION COMPLETED:
02:17 PM
NARRATIVE
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Licensing Program Analyst (LPA), Robert Maciel made an unannounced Plan of Correction (POC) visit and met with Director, Seasha Robb (S1), for the purpose of following up on outstanding POCs that were due by 05/24/2024. During the annual inspection on 04/25/2024, the facility was cited seven violations which include the facility not yet having its its drinking water tested for lead contamination levels, the facility not performing a disaster drill within the last 6 months, not possessing current mandated reporter training certificates for the Director or staff 2 (S2), the Director not possessing proof of immunization against measles, staff 3 (S3) not possessing a complete LIC503 Health Screening, S1, S2, and S3 not possessing complete LIC501 Personnel Records, and child 5 (C5) not possessing record of immunization.

During today's visit, LPA observed no children in care. LPA requested facility and children's records. Director stated she had not yet had faucets used for drinking or food preparation tested for lead, did not record a disaster drill within the last 6 months, did not possess current mandated reporter training certificates for herself or S3, did not possess proof of immunization against measles for herself, did not possess a complete LIC503 Health Screening for S3, and did not possess complete LIC501 Personnel Records for herself, S2, and S3. Director stated that C5 is no longer enrolled in the facility.

The following violations of the California Code of Regulations Title 22 were cited. Please see LIC809-D. Appeal Rights were provided. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director, Seasha Robb.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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 4
Document Has Been Signed on 09/12/2024 02:03 PM - It Cannot Be Edited


Created By: Robert Maciel On 09/12/2024 at 01:31 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BOONT TRIBE COMMUNITY SCHOOL P/S
FACILITY NUMBER: 233009794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2024
Section Cited
HSC
1597.16(a)(1)

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(1) A licensed child day care center, as defined in Section 1596.76, that is located in a building that was constructed before January 1, 2010, shall have its drinking water tested for lead contamination levels on or after January 1, 2020, but no later than January 1, 2023, and every five years after the date of the initial test.

This requirement is not met as evidenced by:
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Director stated that she would have the faucet in the kitchen tested for lead according to the written directives in PIN 21-21.1 and send completed forms to LPA by email at robert.maciel@dss.ca.gov.
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Based on interview, water fountains used for drinking or food preparation were not tested for lead contamination which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/26/2024
Section Cited
CCR101174(d)

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(d) Disaster drills shall be conducted at least every six months.

This requirement is not met as evidenced by:
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Director stated she would perform a disaster drill, record it, and send a picture of the record to LPA by email at robert.maciel@dss.ca.gov
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Based on interview, the director did not conduct a disaster drill within the past 6 months which poses a potential health, safety or personal rights risk to persons in care.
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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 Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2024 02:03 PM - It Cannot Be Edited


Created By: Robert Maciel On 09/12/2024 at 01:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BOONT TRIBE COMMUNITY SCHOOL P/S
FACILITY NUMBER: 233009794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2024
Section Cited
HSC
1596.8662(b)(1)

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(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
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Director stated she would obtain current mandated reporter training certificates for S1 and S3 and send a copy to LPA by email at robert.maciel@dss.ca.gov.
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Based on record review, staff 1 (S1) and staff 3 (S3) did not possess current Mandated Reporter Training Certificates which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/26/2024
Section Cited
HSC1596.7995(a)(1)

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(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a day care center if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
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Director stated she would obtain proof of immunization against measles for herself and send a copy to LPA by email at robert.maciel@dss.ca.gov.
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Based on record review, the director (S1) did not possess proof of immunization against measles which poses a potential health, safety or personal rights risk to persons in care.
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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 Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2024 02:03 PM - It Cannot Be Edited


Created By: Robert Maciel On 09/12/2024 at 01:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BOONT TRIBE COMMUNITY SCHOOL P/S
FACILITY NUMBER: 233009794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/26/2024
Section Cited
CCR
101216(g)(1)

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(1) Except as specified in (3) below, good physical health shall be verified by a health screening, including a test for tuberculosis, performed by or under the supervision of a physician not more than one year prior to or seven days after employment or licensure.

This requirement is not met as evidenced by:
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Director stated she would obtain staff 3's LIC501 Health Screening and send a copy to LPA by email at robert.maciel@dss.ca.gov.
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Based on record review, staff 3 (S3) did not possess a compelte LIC503 Health Screening which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/26/2024
Section Cited
HSC101217(a)

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(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
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Director stated she would obtain complete LIC501 Personnel Records for S1-S3 and send a copy to LPA by email at robert.maciel@dss.ca.gov.
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Based on record review, staff 1 - 3 (S1-S3) did not possess a complete Personnel Record which poses/posed a potential health, safety or personal rights risk to persons in care.
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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 Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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