<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280108344
Report Date: 04/10/2025
Date Signed: 04/10/2025 03:34:00 PM

Document Has Been Signed on 04/10/2025 03:34 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 CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CANV KIDS DEVELOPMENT & FAMILY PROGRAM AKA LOS NINFACILITY NUMBER:
280108344
ADMINISTRATOR/
DIRECTOR:		KATHY PEEBLESFACILITY TYPE:
850
ADDRESS:1510 MYRTLE AVENUETELEPHONE:
(707) 253-4482
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 37DATE:
04/10/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Evelyn Fuentes, Site SupervisorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/10/25 a subsequent unannounced Case Management inspection was made by Licensing Program Analyst (LPA), Cindy Castro, in response to an Unusual Incident Report (UIR) that occurred on 03/31/25. In which video footage showed a staff dancing provocatively and pulling her clothes off during naptime. The incident was self-reported and submitted as Unusual Incident Report to the Department.

During today's inspection LPA conducted child interviews and interview with Site Supervisor Evelyn Fuentes who was absent during initial inspection conducted on 04/03/25. One child interview revealed that incident that occurred on 03/31/25 was observed by that child and corroborated the incident.

During a prior visit on conducted on 04/03/25 interviews with Staff (S2-S4) revealed that there were multiple occasions in which staff (S1) was observed dancing inappropriately, with children present. Staff reported that S1 would “joke dancing provocatively” and would also lift her apron and ask if clothes worn were appropriate. Staff also reported that S1 was inappropriate and would put herself in the visual line of the camera and dance inappropriately. Two staff reported that they informed superiors of S1’s inappropriate behaviors. S1’s employment was terminated, and proof was provided to the Department.

The following Title 22, Children’s Personal Rights Violations, CCR Code 101223 (a) (1), were cited. Site Supervisor was advised that children have personal rights including to have a dignified relationships with staff. That staff need to conduct themselves in an appropriate manner while working with children and not violate children’s personal rights. That staff are mandated reporters and should be reporting inappropriate conduct to superiors when observed. LPA C. Castro provided Site Supervisor with a copy of Children's Personal Rights Regulations and a plan of correction was discussed with Site Supervisor.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Cindy Castro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CANV KIDS DEVELOPMENT & FAMILY PROGRAM AKA LOS NIN
FACILITY NUMBER: 280108344
VISIT DATE: 04/10/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The following violations of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided and discussed.

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.

Exit interview conducted, and report was reviewed with Site Supervisor Evelyn Fuentes.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Cindy Castro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/10/2025 03:34 PM - It Cannot Be Edited


Created By: Cindy Castro On 04/10/2025 at 01:42 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: CANV KIDS DEVELOPMENT & FAMILY PROGRAM AKA LOS NIN
FACILITY NUMBER: 280108344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2025
Section Cited
CCR
101223(a)(1)

1
2
3
4
5
6
7
101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:(1)To be accorded dignity in his/her personal relationships with staff and other persons.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
S1's employement was terminated on 04/01/25. Site Supervisor stated Center Staff will complete a training about Children’s Personal Rights, Center policies regarding appropriate conduct when being around children, and Mandated Reporting. An attendance log with signatures will be submitted to the department 05/09/25 via email, mail or fax.
8
9
10
11
12
13
14
Based on the observations and interviews the licensee did not meet the requirement of children having a dignified relationship with staff. As evidence by a child observing S1 dancing provocatively and pulling pants down, which poses/posed a potential health, safety or personal rights risk to children in care.
8
9
10
11
12
13
14
Via mail, email, or fax. Email:
cindy.castro@dss.ca.gov Fax: 707-588-5099

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Cindy Castro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4