<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009958
Report Date: 08/15/2022
Date Signed: 08/15/2022 12:54:16 PM

Document Has Been Signed on 08/15/2022 12:54 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: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: 22CENSUS: 16DATE:
08/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jeanette BoehmTIME COMPLETED:
01:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Amy Strother conducted an unannounced Case Management Inspection in regard to a written unusual incident report (UIR) submitted to Community Care Licensing (CCL) on 07/25/22. LPA met with Jeanette Boehm.

On 07/21/22 Licensee Jeanette Boehm (L1) reported by telephone to the Child Care On Duty Officer that on 07/19/22, Staff 1 (S1) picked up Child 1 (C1) and carried her to the hand washing line, scratching C1’s underarm, leaving a mark. It was reported by L1 that while C1 was crying, S1 told C1, “Waa, Waa, Waa, stop your crying.” The written report stated that L1 terminated Staff 1's (S1’s) employment after watching the incident on the facilities camera footage. L1 submitted video footage of the incident to CCL on 07/25/22. A photo was taken of C1’s underarm on 07/19/22. The photo shows a red scratch mark with broken skin. The photo was submitted to CCL on 07/26/22.

L1 stated that no other staff person witnessed the incident. The UIR stated that C1 told Staff 2 (S2) that S1 hurt her. S2 observed the scratch on C1’s underarm and took a photo of it. S2 informed L1 and C1’s mother about the incident on 07/19/22. L1 stated in a telephone conversation with LPA Strother on 08/09/22 that she became aware of S1 saying, “Waa, Waa, Waa, stop your crying” to C1 when viewing the video footage. The incident occurred between 11:49am and 11:51am.

During today's visit, LPA observed 3 staff in the toddler play ground with 7 toddler age children, and 4 staff with 9 preschool children inside the preschool room.

The following violation of the California Code of Regulations, Title 22; Division 12, were cited: see LIC 809-D. Appeal Rights were provided.

LPA Strother informed licensee Jeanette Boehm that this report dated 08/15/22 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, and personal rights of children in care.

LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CENTER
FACILITY NUMBER: 493009958
VISIT DATE: 08/15/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Also, LPA Strother informed the licensee to provide a copy of this licensing report dated 08/15/22, that documents a Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with License, Jeanette Boehm. 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: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/15/2022 12:54 PM - It Cannot Be Edited


Created By: Amy Strother On 08/15/2022 at 11:32 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2022
Section Cited
CCR
101223(a)(3)

1
2
3
4
5
6
7
(a)The licensee shall ensure that each child is accorded the following personal rights: (3) 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…
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
L1 stated that she has taken action by terminating S1, hosted a training on the topic of Personal Rights for all currently employed staff and has given each current staff a copy of the Title 22 Personal Rights regulations. By 08/16/22 L1 will create and submit to LPA Strother a written plan (to include date, time
8
9
10
11
12
13
14
On 07/19/22 S1 picked up C1 and carried her to the hand washing line, scratching C1’s underarm, leaving a mark. It was reported by L1 that while C1 was crying, S1 told C1, “Waa, Waa, Waa, stop your crying”, which poses an immediate Health and Safety risk to children in care.
8
9
10
11
12
13
14
and persons who will attend) a staff training to discuss techniques to use for smooth transitions with children. L1 will have staff sign in as documentation that they have completed the training, submitting the sign-in sheet to LPA Strother by 08/29/22.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3