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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010175
Report Date: 07/29/2022
Date Signed: 07/29/2022 12:46:57 PM

Document Has Been Signed on 07/29/2022 12:46 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:NORTHGATE CHRISTAIN FELLOWSHIP - INFANTFACILITY NUMBER:
483010175
ADMINISTRATOR:AMANDA VERBISFACILITY TYPE:
830
ADDRESS:2201 LAKE HERMAN ROADTELEPHONE:
(707) 315-7124
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 20TOTAL ENROLLED CHILDREN: 20CENSUS: 0DATE:
07/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Amanda VerbisTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Glenn Ouye met with Director and licensee representative Amanda Verbis to conduct the prelicensing inspection for this combination center. The applicant has applied for an infant, preschool and school age program. The application was received on March 7, 2022. The fire local fire inspector is waiting for the building department to complete the review of the facility blueprints before the final fire safety inspection can be approved.

The infant application is for 20 infants. The facility has two infant rooms. There is sufficient interior square footage for the 20 infants. One room will be used for younger non-mobile infants and the other room will be used for mobile infants. There are age appropriate equipment, furniture and toys for the children. There are changing tables in each room within arms reach of sinks. There are sufficient cribs for children that need cribs and sleeping mats for infants that have graduated from cribs. There is a refrigerator to store breast milk and formula. The sign in and sign out procedure was discussed.

There are functioning smoke and carbon monoxide detectors. There is a fire extinguisher rated at 3A40BC. The facility will conduct emergency disaster drills at least once every six months. The facility agrees to document the disaster drill.

The outdoor activity area has sufficient square footage for the 20 infants. The is age appropriate equipment and toys for the children. The infant program will request a waiver to share the outdoor activity space with the two year old children of the preschool program on a rotational basis.

The Applicant was reminded that all adults 18 years and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NORTHGATE CHRISTAIN FELLOWSHIP - INFANT
FACILITY NUMBER: 483010175
VISIT DATE: 07/29/2022
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LPA reviewed with applicant the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed - related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

LPA discussed the safe sleep regulations with applicant 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 applicant 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.

Exit interview conducted and report was reviewed with the applicant, Amanda Verbis.

Upon receipt of the approved fire clearance the facility will be approved for licensure.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022
LIC809 (FAS) - (06/04)
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