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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483010798
Report Date: 04/10/2025
Date Signed: 04/10/2025 03:07:27 PM

Document Has Been Signed on 04/10/2025 03:07 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:FAIRFIELD PRESCHOOL & CHILDCAREFACILITY NUMBER:
483010798
ADMINISTRATOR/
DIRECTOR:		VERMA, MONIKAFACILITY TYPE:
860
ADDRESS:1004 UTAH STREETTELEPHONE:
(901) 240-7791
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 0DATE:
04/10/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Monika VermaTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Continued after LPAs arrival

LPAs toured and measured the on-limits areas and classrooms located at the facility. The facility has a total of 2 buildings and 3 classrooms.

Infant Classroom measurements are:
The Indoor total measurements contain a total of 588 square feet, which will accommodate Applicant’s request for 5 infant children.

Preschool Classroom measurements are:
The Indoor total measurements contain a total of 868 square feet, which does not accommodate Applicant’s request for 35 preschool children. The indoor total measurements accommodate for a total of 24 preschool children.

School Age Classroom measurements are:
The Indoor total measurements contain a total of 665 square feet, which will accommodate Applicant’s request for 10 school age children but can also accommodate to 15 school age children per LPAs measurements. LPAs continued to tour the facility and measured all outdoor activity space.

Infant Outdoor Play measurements are:
The outdoor total measurements contain a total of 380 square feet, which will accommodate Applicant’s request for 5 infant children.

Preschool Outdoor Play measurements are:
The outdoor total measurements contain a total of 3652 square feet, which will accommodate Applicant’s request for 35 preschool children.

School Age Outdoor Play measurements are:
The outdoor total measurements contain a total of 3652 square feet, which will accommodate Applicant’s request for 10 school age children. Applicant is anticipating for the school age children and preschool children to share the outdoor yard and will submit a waiver request.
NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
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 7
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)
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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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAIRFIELD PRESCHOOL & CHILDCARE
FACILITY NUMBER: 483010798
VISIT DATE: 04/10/2025
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Indoor/Children’s Area:
LPAs observed all classrooms to be clean, safe, sanitary and in good repair. A comfortable temperature for children shall be maintained at all times. Furniture and equipment were observed to be maintained in good condition, free of sharp, loose or pointed parts. All materials and surfaces accessible to children, including toys, shall be free of toxic substances. All play equipment and materials used by children were observed to be age-appropriate. LPAs observed no fireplace or open face heaters. LPAs observed fully charged fire extinguisher, carbon monoxide and smoke detectors in the facility. There are 25 chairs, 1 feeding chair, 4 tables, 12 mats, 4 toilets and 4 sinks for the infants, preschoolers, and school age children.

Per applicant there will be no potty training in infant room. Applicant was advised that feeding chairs or other appropriate seating equipment shall be used to seat infants during feeding. Staff have separate bathroom that can be utilized by sick children if needed. Sick children will be isolated in the office area of the facility. LPA observed that items that may pose a danger to children were stored in locked storage rooms inaccessible to children. LPA observed no containers with tight-fitting lids for the disposal of solid wastes. LPA informed applicant to ensure that a container with a tight-fitting lid is stored in facility to dispose of solid wastes. LPA advised that Applicant maintains first-aid supplies in a location accessible to staff but inaccessible to children.

LPAs observed infant changing table not within arms reach to the sink. Applicant informed LPAs that she will be moving the changing table in the bathroom next to the infant nap room. Applicant stated that parents will provide food and milk bottles for infants. LPAs advised Applicant that as per Title 22 regulations, bottles and dishes provided by authorized representatives shall be rinsed and returned to authorized representatives for sanitizing at the end of each day.

Lunch and two snacks are provided by parents. Applicant was advised that full-day programs shall ensure that each child has a lunch, and children shall be free to drink as they wish. Drinking water is readily available for the children via water filter dispenser and will be switched to a drinking water tank under the sink. LPAs observed a kitchen/ food preparation area kept clean and free of litter and rubbish; Applicant was advised that measures shall be taken to keep kitchen areas free of rodents and other vermin.

Outdoor:
Outdoor area for infant, preschool, and school age children were free of hazards including, holes, broken glass dry grasses, and other debris that pose a fire hazard. Shade was provided by large tree in the middle of the preschool yard, shade is needed for the infant play yard. The playground is enclosed by a fencing around the facility to protect children, fence is at least 4 feet high. LPAs observed no bodies of water. Any construction or equipment that could pose a hazard in the outdoor activity area shall be made inaccessible to children in care.
NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
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)
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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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAIRFIELD PRESCHOOL & CHILDCARE
FACILITY NUMBER: 483010798
VISIT DATE: 04/10/2025
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Drinking water from a non-contaminating fixture or container shall be readily available both indoors and in the outdoor activity area. LPAs advised per Health and Safety Code 1597.16(a)(1) Lead Testing and PIN-21-21-CCP Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010 to test their drinking water for lead contamination between January 1, 2020 and January 1, 2023, and then every 5 years after the date of the first test.

Per Written Directive 100700(c)(1) Written Directives for Lead Testing (1) For a license issued on or after July 1, 2022, initial testing results shall be received and posted within 180 days of licensure.

This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. A Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

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.

Applicants were informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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 platforms. 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.
NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
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: 4 of 7
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: FAIRFIELD PRESCHOOL & CHILDCARE
FACILITY NUMBER: 483010798
VISIT DATE: 04/10/2025
NARRATIVE
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The following corrections are needed before a licensure will be considered.
1. Final review of application packet by LPM
2. Submit LIC 200A with corrected capacity and age requests.
3. A new fire clearance will be required to match updated capacity.
5. Install kitchen gates to make kitchen inaccessible for children.
6. Submit IMS Plan
7. Lock janitor closet.
8. Install swing set with anchoring.
9. Provide manufacturer’s label for play structure.
10. Install cushioning for outdoor area.
11. Submit outdoor waiver request per regulation 101238.2(a).
12. Install shade structure for infant play yard.
13. Move infant changing table to have sink within arm’s reach per regulation 101439(h).
14. Ensure infant changing table contains raised sides to meet standard regulation 101439(h).
15. Send proof of trash can with tight fitting lid for diapering.
16. Send proof of total number of highchairs to meet requested capacity.
17. Submission of the following application corrections per LPM listed below:
a. LIC 308:

i. Ensure designated employee's full name is listed

b. LIC 309:

i. Ensure Page 2 is completely blank, you should only be filling out the section that pertains to your entity.

ii. Ensure your LLC number is correct on Page 1, your LLC number should match the number on the Secretary of State.

c. LIC 500:

i. Submit for Preschool Component, only need 2 more staff positions listed.

NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
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)
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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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FAIRFIELD PRESCHOOL & CHILDCARE
FACILITY NUMBER: 483010798
VISIT DATE: 04/10/2025
NARRATIVE
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LIC 610:

i. Submit for Preschool and School Age component.

ii. Submit permission agreements for the 2 selected temporary relocation sites.

e. LIC 999:

i. Resubmit LIC 999 as it is hard to read.

f. Submit Operating Agreement specifying who will manage the business, who the owner is, how decisions will be made, who can make the decisions, etc.

g. Job Descriptions:

i. Revise Job Description to include line of supervision over children.

h. Personnel Policy:

i. Explain hours of work shifts and work hours.

ii. Ensure Department of Justice is mentioned.

iii. Implement more detailed guidelines for facilities abuse reporting procedure (what agency are they reporting to? How long do they have to report?)

i. In Service Training:

i. Implement the following topics into training: Provision of Child Care, Supervision, and Communication; Assistance with Prescribed medication that are self administered; Recognition of early signs of illnesses and the need for professional assistance; Availability of community services and resources.

j. Parent Handbook:

NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
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: 7 of 7
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: FAIRFIELD PRESCHOOL & CHILDCARE
FACILITY NUMBER: 483010798
VISIT DATE: 04/10/2025
NARRATIVE
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i. Amend Parent Handbook to provide more in depth detail pertaining to IMS Plans (not only limited to nebulizers).

k. Admission Agreement:

i. Amend Admission Agreement to include Modification Conditions pertaining to notification of rate changes.

ii. Amend Admission Agreement to include Rights of Licensing Agency.

iii. Amend Admission Agreement to include Termination Conditions.

l. Ensure Fingerprints are associated with new facility number. Submit a copy of your driver's license and LIC form 9182.

An exit interview was conducted with the above items discussed. This report was provided to Monika Verma, Applicant Representative. Final license determination will be made upon review by the Licensing Program Manager.



An additional visit may be required.
NAME OF LICENSING PROGRAM MANAGER: Mai Lor
NAME OF LICENSING PROGRAM ANALYST: Jaelyn Agbayani
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)
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