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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009958
Report Date: 04/23/2021
Date Signed: 04/23/2021 02:00:11 PM

Document Has Been Signed on 04/23/2021 02:00 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTERFACILITY NUMBER:
493009958
ADMINISTRATOR:BOEHM, JEANETTEFACILITY TYPE:
850
ADDRESS:530 NORTH CLOVERDALE BLVDTELEPHONE:
(707) 318-3951
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 7DATE:
04/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Liliana Lara LopezTIME COMPLETED:
01:38 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amy Strother conducted an unannounced case management Tele-Inspection with Teacher, Liliana Lara Lopez (S3) in response to an Unusual Incident/Injury notification reported by telephone to the department on 04/16/21. Due to COVID-19, the Department has suspended all field operations. S3 agreed to a FaceTime conference with LPA for the Tele-Inspection. On 04/16/21 Licensee Jeanette Boehm (L1) reported by telephone to the Child Care On Duty Officer that L1 terminated Staff 1's (S1’s) employment due to S1 "smacking Child 1’s (C1’s) right arm and leaving a red mark." L1 stated that she was present at the center but was not in the classroom when the incident occurred. L1 stated that teacher's aide, Staff 2 (S2) was present in the classroom with S1 when the incident occurred but did not observe S1 smack C1's arm due to her back being turned. L1 stated that C1 began crying and when asked by S2 why they were crying, C1 replied that S1 smacked their arm. L1 stated that the incident was caught on the facility's security camera. L1 stated that the incident occurred between 9:09am and 9:11am on 04/16/21. L1 stated that it appeared that S1 "smacked the child's arm because he wanted the child to stop running by him." On 04/19/21 L1 cross reported the incident to CCLD and CPS, including a photo of C1’s arm and video footage, as directed by the Department. A written Unusual Incident Report was received by the Department on 04/23/21.

During today's tele-visit, LPA observed 3 staff in the toddler room with 7 toddler age children. S3 stated that the toddler room was the only classroom in operation during today's tele-inpection. LPA conducted interviews with S2 and S3.

The following violation of the California Code of Regulations, Title 22; Division 12, were cited: see LIC 809-D. Appeal Rights were provided.
Reports citing Type A violations are to be provided to parents/guardians of children currently enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC 9224 to be kept in each child's file.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 04/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2021
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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Document Has Been Signed on 04/23/2021 02:00 PM - It Cannot Be Edited


Created By: Amy Strother On 04/23/2021 at 11:23 AM
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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTER
FACILITY NUMBER: 493009958

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2021
Section Cited
CCR
101223(a)(3)

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Personal Rights. To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting; or withholding shelter, clothing, medication or aids to physical functioning.
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S3 stated that L1 has fired S1 and will not allow S1 to work at the facility in the future. S3 stated that she will work with L1 to put together a staff training and hold a a staff meeting on the topics of Personal Rights and Positive Disipline by 4/30/21.
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This requirement is not met as evidenced by video footage, photo documentation and statements by facility staff that S1 smacked his hand on C1’s right arm several times, causing red marks to C1’s right arm on 04/16/21 at 9:09am. This poses an immediate health and safety risk to the children in care.
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L1 will submit staff training/meeting notes with signatues of staff in attendance to LPA Strother via email by 04/30/21.
amy.strother@dss.ca.gov

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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:Alexis Hollon
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2021


LIC809 (FAS) - (06/04)
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