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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009258
Report Date: 11/04/2025
Date Signed: 11/04/2025 05:04:28 PM

Document Has Been Signed on 11/04/2025 05:04 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:4CS CLOVERDALE PRESCHOOLFACILITY NUMBER:
493009258
ADMINISTRATOR/
DIRECTOR:		LAURA GUZMANFACILITY TYPE:
850
ADDRESS:330 N. WASHINGTON STREETTELEPHONE:
(707) 894-9011
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 30TOTAL ENROLLED CHILDREN: 24CENSUS: 12DATE:
11/04/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:04 PM
MET WITH:Jacqueline Sanchez - Teacher and Laura Guzman - DirectorTIME VISIT/
INSPECTION COMPLETED:
05:18 PM
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An annual random inspection was made to the facility by Licensing Program Analysts (LPAs), Amy Strother and Jessica Gaumann. LPAs met with facility representative, Teacher Jacqueline Sanchez (S1) and then Director, Laura Guzman (D1) took over the inspection at 4:00pm. Facility representative was reminded that all adults 18 and over, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

The facility’s operating hours are 7:00am-5:30pm, Monday-Friday, year round. The facility was toured inside and outside, and the floor and yard plan submitted by the licensee was verified. Sign in/out records were reviewed and in compliance. Items which could pose a danger to children (such as detergents, cleaning compounds and medications) were observed to be inaccessible to children located on high shelves out of reach of children. D1 stated there are no poisons in the facility, and none were observed during this inspection. LPAs observed 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 by use of individual water bottles that are refilled as needed. The children's bathroom is in safe and sanitary condition. The center’s isolation area for any child who becomes ill while in care, is located in the staff office. LPAs observed food prep areas are clean. Food is properly stored and refrigerated as needed. There was no contaminated food observed. Garbage cans containing solid waste have tight fitting lids. Menus are posted in the front entry of the school.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2025
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)
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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: 4CS CLOVERDALE PRESCHOOL
FACILITY NUMBER: 493009258
VISIT DATE: 11/04/2025
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PAGE 2

LPAs observed a working carbon monoxide and smoke detector in the facility. LPAs observed a fire extinguisher that appeared charged in the facility. LPAs observed the playground equipment and surface areas were in safe condition.

There is wood chip cushioning underneath the climbing structure to absorb falls. There were no bodies of water observed on the site. D1 stated no weapons are stored on site, and none were observed.

During today's inspection, staffing ratios were being met, a total of 12 preschool children were being supervised by 4 staff. The facility was operating within the licensed capacity and ratio requirements. During the inspection S1 possessed current CPR and First Aid certifications, certificate expires 09/2026. When S1 left for the day, D1 had a current certificate on file, certificate expires 09/2026.

Five children’s records were reviewed and contained complete and current information as required. Four staff files were reviewed and contained all records as required.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

LPA verified that the lead testing was completed in accordance to the Written Directives outlined in PIN 21-21.1-CCP

This facility provides Incidental Medical Services – IMS. LPAs reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. 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 are available at: https://www.ada.gov/resources/child-care-centers/.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC809 (FAS) - (06/04)
Page: 3 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: 4CS CLOVERDALE PRESCHOOL
FACILITY NUMBER: 493009258
VISIT DATE: 11/04/2025
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Licensee was informed of the MyChildCarePlan.org website; 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.

A notice of site visit was given to facility reprecentative and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with facility representative, Laura Guzman.

There were no Title 22 deficiencies cited during today's inspection.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4