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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483007424
Report Date: 09/29/2022
Date Signed: 09/29/2022 03:51:29 PM

Document Has Been Signed on 09/29/2022 03:51 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MUSTARD SEED PRESCHOOLFACILITY NUMBER:
483007424
ADMINISTRATOR:NOGALIZA, DANNIELLEFACILITY TYPE:
850
ADDRESS:901 SOLANO AVE.TELEPHONE:
(707) 557-7928
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 42TOTAL ENROLLED CHILDREN: 30CENSUS: 28DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Dannielle Nogaliza - Center DirectorTIME COMPLETED:
04:10 PM
NARRATIVE
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A Required-1 Year inspection was made to the facility by Licensing Program Analyst (LPA), M. Augustin. The facility file was reviewed prior to this visit. 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. Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. The preschool program has a combination toddler component and a waiver for the preschool to share the outdoor play space with the toddler program is on file. This program is not a Title 5 funded program.

The facility’s operating hours are 8:30am - 4:00pm, Monday-Friday. The facility was toured inside and outside and the floor and yard plan submitted by the licensee were verified. The items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children. LPA did not observe any poison(s). The toys, floors, desks and other equipment and surfaces are clean, toxic free, safe and in good condition. There is drinking water available to children both indoors and outdoors. The facility provides the children with paper cups to retrieve water from a water cooler with a filtration system. The children's bathrooms are in safe and sanitary condition. Food prep areas are clean. Food is properly stored and refrigerated as needed. There was no contaminated food observed. A written Menu that is at least one week in advance was not produced or posted in an area accessible for review by the children's authorized representative. The facility did not furnish a written contingency plan for action during fires, floods and earthquake. The First Aid kit in the Preschool class did not contain Sterile dressing, Tweezer, antiseptic solution. The Daily Activities schedule, the Emergency Disaster Plan (LIC 610), and Parents’ Rights (PUB 393) were posted in each classroom. The local county public health department contact information was posted. Garbage cans containing solid waste have tight fitting lids. LPA observed a working carbon monoxide detector and smoke detector, and a fully charged fire extinguisher rated at least 2A10BC. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 09/29/2022 03:51 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 09/29/2022 at 01:10 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: MUSTARD SEED PRESCHOOL
FACILITY NUMBER: 483007424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101174(b)(2)
Disaster and Mass Casualty Plan
(b) The plan shall be subject to review by the Department and shall include: (2) Contingency plans for action during fires, floods and earthquakes including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and the Director confirming she did not have a written contigency plans for actions during fire, floods and earthquakes. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Center Director stated she would produce a contingency plan for action during fire, floods and earthquakes, and CD intends to submit a copy of the plan to the Department by 10/13/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Type B
Section Cited
HSC
1596.7995(a)(1)
General Provisions and Definitions
(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:
Deficient Practice Statement
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Based on four staff (S1-S3 & CD) records reviewed at 10:45am which revealed S3's record did not contain proof of immunity against the Mesles. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Center Director stated she would ensure that S4 obtained proof of immunity against the Measles and CD would submit S3's required immunization to the Department by 10/13/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


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Document Has Been Signed on 09/29/2022 03:51 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 09/29/2022 at 01:10 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: MUSTARD SEED PRESCHOOL
FACILITY NUMBER: 483007424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101216(g)(1)
Personnel Requirements
(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:
Deficient Practice Statement
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Based on four staff (S1-S3 & CD) records reviewed at 10:45am which revealed S3's record did not contain Health Screening (LIC 503). The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Center Director stated she would ensure that S3 complete the LIC 503 and CD would submit a completed copy of S3's LIC 503 to the Department by 10/13/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Type B
Section Cited
CCR
101217(a)(6)
Personnel Records
(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: (6) Documentation of the educational background, training and/or experience specified in this chapter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on four staff (S1-S3 & CD) records reviewed at 10:45am which revealed S1-S3's records were either missing or had various incomplete licensing forms. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Center Director stated she would review staff records and ensure that incompleted licensing are either signed or completed, and CD would submit evidence of completion of the completed forms to the Department by 10/13/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


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Document Has Been Signed on 09/29/2022 03:51 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 09/29/2022 at 01:10 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: MUSTARD SEED PRESCHOOL
FACILITY NUMBER: 483007424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101229.1(a)(1)
Sign In and Sign Out
(a) In addition to the sign-in procedure requirement of Section 101226.1(b), the licensee shall develop, maintain and implement a written procedure to sign the child in/out of the child care center that shall, at a minimum, include the following: (1) The person who signs the child in/out shall use his/her full legal signature and shall record the time of day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a review of the children's sign in/out procedure which confirmed several children had not been signed out on various dates. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Center Director stated she would produce a letter and provide parents with the letter to remind them to sign in/out, and she would position a staff during drop off/pick up time to ensure parents were signing their child(ren) in/out. CD intends to submit a copy of the letters submitted to parents as well as a written plan to show how the facility intends to comply with the regulations.
Type B
Section Cited
CCR
101227(a)(6)
Food Service
(6) Menus shall be in writing and shall be posted at least one week in advance in an area accessible for review by the child's authorized representative. Copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the child's authorized representative and the Department upon request.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and Center Director's statement confirming she had not produce and/or posted a written menu that was at least week in davance. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Center Director stated she would produce a menu and CD stated she would submit a copy of the menu as well as a photograph of the menu posted on the wall. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


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Document Has Been Signed on 09/29/2022 03:51 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 09/29/2022 at 01:10 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: MUSTARD SEED PRESCHOOL
FACILITY NUMBER: 483007424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101429(a)(2)(B)
Responsibility for Providing Care and Supervision for Infants
(B) Staff shall physically check on sleeping infant(s) every 15 minutes and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the Director not furnishing evidence to prove that staff had/were conducting 15 minute checks while a child (C5) under 24 months slept/napped. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Center Director stated she would document at least one week of 15 minute checks on the Infant Sleep Log for C5 and CD intends to submit copy of the log to the Department by 10/13/22. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Type B
Section Cited
CCR
101439.1(b)
Infant Care Center Sleeping Equipment
(b) A crib or portable -crib meeting United States Consumer Product Safety Commission safety standards shall be provided for each infant who is unable to climb out of a crib.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation of not seeing a crib and an interview with S3 which confirmed C5 could not climb out of a crib and C5 napped on a cot. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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The facility had two cribs currently in storage and Center Director intends to obtain fitted sheets for the cribs and to position the crib in the Toddler classroom for C5 to nap, and the Director would submit a photograph to show the installation of the new crib inside the classroom. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099 .
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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


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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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MUSTARD SEED PRESCHOOL
FACILITY NUMBER: 483007424
VISIT DATE: 09/29/2022
NARRATIVE
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The playground was free of hazards. The playground equipment and surface areas were in safe condition. There is foam and artificial turf cushioning underneath climbing structures and/or play equipment to absorb falls. There is a canopy for shade area. There were no bodies of water observed. The Center Director stated no weapons are stored on site and none were observed. The facility roster was reviewed and appeared to be complete. During today's inspection, staffing ratios were being met, and 28 children were being supervised by three teachers and one aide.

The facility was operating within the licensed capacity. CD and three staff (S1-S3) possessed a current EMSA approved Pediatric CPR and First Aid certification, and CD’s certification expire on 08/2024. The sign-in/sign-out procedure was reviewed and was not in compliance. A review of the sign in/out procedure revealed that several children had not been signed out on various dates. Four staff (CD, & S1-S3) records were reviewed at 10:45am and staff records reviewed revealed S1 was missing Personnel Record (LIC 501), S2 was missing LIC 9095, LIC 501 & 508 were incomplete, and S3’s record did not contain proof of immunity against the Measles, LIC 501, Health Screening (LIC 503), and Evaluation of Teacher’s Qualification (LIC 9095). Eight (C1-C8) children’s records were reviewed at 12:00pm and contained signed admission agreements, Consent for Emergency Medical Treatment, Physician’s Report, Immunization Record (IR) and IR transcribed onto CDPH 286. The facility conducted an emergency disaster drill within last six months and the last drill was conducted on 09/13/22. During the inspection, S3 confirmed there were two children under 24 months old enrolled into care, C5 could not climb out of a crib and napped on a cot, and CD did not furnish evidence to prove that 15 minutes checks had/was being conducted for C5. CD also did not furnish an Infant Needs and Service Plan for C5.

This facility is not providing Incidental Medical Services (IMS). The Department’s IMS policy was discussed with the Center Director. 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 and The Effects of Lead Exposure brochures, were reviewed and discussed with the Center Director. All licensing reports are public information and must be made available upon request for at least three years. (Continue to LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MUSTARD SEED PRESCHOOL
FACILITY NUMBER: 483007424
VISIT DATE: 09/29/2022
NARRATIVE
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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 the Center Director, Dannielle Nogaliza. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

LPA discussed the safe sleep regulations with facility representative and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 09/29/2022 03:51 PM - It Cannot Be Edited


Created By: Melchisedeck Augustin On 09/29/2022 at 02:08 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: MUSTARD SEED PRESCHOOL
FACILITY NUMBER: 483007424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101419.2(a)
Prior to the infant's first day at the center, the infant care center director or assistant director shall complete a needs and services plan for the infant.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on eight children's (C1-C8) records reviewed at 10:45am and interview with Director and S3 confirming a child under 24 months old did not have an Infant Needs & Service Plan on file. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/13/2022
Plan of Correction
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Center Director stated the facility would create an Infant Needs and Service Plan for C5, and CD intends to submit a copy of C5's completed plan to the Department by 10/13/22 via mail, email or fax. Email: melchisedeck.augustin@dss.ca.gov & Fax: 707-588-5099
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Leslie Lepori
LICENSING EVALUATOR NAME:Melchisedeck Augustin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022


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