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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493006190
Report Date: 05/08/2024
Date Signed: 05/08/2024 04:37:13 PM

Document Has Been Signed on 05/08/2024 04:37 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:4CS WINDSOR STATE PRESCHOOLFACILITY NUMBER:
493006190
ADMINISTRATOR/
DIRECTOR:		MICHELLE MARTINFACILITY TYPE:
850
ADDRESS:79 PLEASANT AVENUETELEPHONE:
(707) 836-7068
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 40TOTAL ENROLLED CHILDREN: 40CENSUS: 17DATE:
05/08/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Michelle MartinTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Glenn Ouye met with Site Supervisor Michelle Martin regarding a self reported incident which occurred on May 2, 2024 where child C1 alleged that a teacher handled C1 in a rough manner.

LPA Ouye attempted to interview child C1 but the interview was unsuccessful due to other students and activities. LPA will return on another day to attempt to interview C1 again. LPA was able to interview staff during the visit.

There were no citations issued during the visit.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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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