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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
280107123
Report Date:
12/17/2024
Date Signed:
12/17/2024 11:07:02 AM
Document Has Been Signed on
12/17/2024 11:07 AM
- 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:
ST. HELENA COOPERATIVE NURSERY SCHOOL
FACILITY NUMBER:
280107123
ADMINISTRATOR/
DIRECTOR:
KELLY, MAUREEN
FACILITY TYPE:
850
ADDRESS:
HWY. 29 AND NIEBAUM LANE
TELEPHONE:
(707) 963-7212
CITY:
RUTHERFORD
STATE:
CA
ZIP CODE:
94573
CAPACITY:
30
TOTAL ENROLLED CHILDREN:
30
CENSUS:
16
DATE:
12/17/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:08 AM
MET WITH:
Maureen Kelly
TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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An unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Mindy Mohr in response to a self-reported Unusual Incident Report (UIR) which was reported to CCL 12/16/2024. LPA met with Director Maureen Kelly.
During today's case management visit there were two staff supervising 16 children. LPA met with D1 to discuss the incident. LPA conducted two staff interviews.
No deficiencies were cited as a result of this case management visit.
This report was read and reviewed with Director Maureen Kelly. Notice of site visit shall be posted for 30 days.
SUPERVISORS NAME
:
Leslie Lepori
LICENSING EVALUATOR NAME
:
Melinda Mohr
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/17/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/17/2024
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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