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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009958
Report Date: 04/07/2022
Date Signed: 04/07/2022 11:56:18 AM

Document Has Been Signed on 04/07/2022 11:56 AM - 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:CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTERFACILITY NUMBER:
493009958
ADMINISTRATOR:BOEHM, JEANETTEFACILITY TYPE:
850
ADDRESS:530 NORTH CLOVERDALE BLVDTELEPHONE:
(707) 894-6037
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 30TOTAL ENROLLED CHILDREN: 18CENSUS: 16DATE:
04/07/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jeanette BoehmTIME COMPLETED:
10:15 AM
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On 04/07/22 Licensing Program Analysts (LPAs) Amy Strother and Glenn Ouye made a visit to the facility for the purpose of verifying that an excluded staff is no longer present in the facility. LPA met with Licensee, Jeanette Boehm (L1). On 02/28/22 the Department's Legal Division issued a Decision and Order stating that Staff 1 (S1) is excluded from any care facility licensed by the Department for the remainder of life, effective 03/10/2022. During the visit LPA did not observe S1 to be present at the facility. L1 stated during the visit that S1 was terminated from employment at the facility on 04/16/21 and has not been at the facility since that date. LPA has verified that S1 is no longer present at the facility.

There were no Title 22 deficiencies cited during today's visit. Appeal Rights were provided.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2022
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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