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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009958
Report Date: 08/25/2022
Date Signed: 08/25/2022 07:46:56 PM

Document Has Been Signed on 08/25/2022 07:46 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: 9DATE:
08/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jeanette BoehmTIME COMPLETED:
07:56 PM
NARRATIVE
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An unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Amy Strother to investigate an incident reported anonymously to Community Care Licensing (CCL) stating that on 08/16/22, staff administered nonprescription medication to a child (C1) in care and did not inform the child’s authorized representative that the medication had been given. The reporting party stated that staff, S1 was informed that C1 had been given medication at home prior to arrival to the facility, and at pick up time C1 appeared “drunk”, struggling to put their shoes on. The reporting party further stated that C1 was given a dose of the 12 hour medication while in care and was experiencing signs of an overdose of the medication. CCL did not receive notification from the facility regarding the incident. During today’s visit, LPA met with the Licensee, Jeanette Boehm to discuss the incident.

At 11:03am LPA reviewed storage of medication and reviewed children’s records. At 11:22am, LPA interviewed L1 and staff S1-S2 beginning at 11:44am. According to the statements provided by L1, L1 was not present when the medication was given to C1 and L1 was unaware that C1 had non-prescription medication at the facility. L1 stated that she believes the medication that was given to C1 was stored in her backpack. Staff interviewed stated that the medication given to C1 on 08/16/22 was provided to the facility by C1's mother and no paperwork was completed. One staff reported that she administered the medication to C1 following the directions on the label and verbally reported to C1's father that the medication had been given to C1 before nap time because C1 was having allergy symptoms and reported that they did not feel well. Staff reported that all staff present at the time were verbally told that C1 was given medication.

Based on information reported to CCL and interview statements provided by L1, S1 and S2 it has been determined that C1 was given a second dose of a 12 hour medication while in care. Based on review of stored medication and review of children’s files the licensee did not obtain, in writing, approval and instructions from the child’s authorized representative for the administration of medication to the child, the administration of medication was not recorded and the facility did not report the incident to the Department (CCL).

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2022
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 4
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: 08/25/2022
NARRATIVE
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The following violation of the California Code of Regulations, Title 22; Division 12, were observed: see LIC809D. This report was read and reviewed with Licensee, Jeanette Boehm. Notice of site visit shall be posted for 30 days. Appeal rights provided.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/25/2022 07:46 PM - It Cannot Be Edited


Created By: Amy Strother On 08/25/2022 at 05:07 PM
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: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2022
Section Cited
CCR
101226(e)(4)(B)

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(4)Nonprescription medications may be administered without approval or instructions from the child's physician if all of the following conditions are met: (B)For each nonprescription medication, the licensee shall obtain, in writing, approval and instructions from the child's authorized representative for the administration of the medication to the child.
This requirement was not met as evidenced by:
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Licensee stated that she is going to write up a written plan on how medication will be handled at the facility, including specific forms to be used, how to use them and will train staff on the written plan and how to use the forms when administering medication to children. Licensee will send written plan and sign in sheet for staff trained to LPA Strother by 09/01/22.
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On 08/16/22 nonprescription medication was given to C1 without written approval from the child's authorized representative, which poses a potenial health and safety risk to the children in care.
This requirement was not met as evidenced by:
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Type B
09/01/2022
Section Cited
CCR101226(e)(5)

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(e)In centers where the licensee chooses to handle medications:(5)The licensee shall develop and implement a written plan to record the administration of prescription and nonprescription medications and to inform the child's authorized representative daily when such medications have been given.
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Licensee stated that she is going to write up a written plan on how medication will be handled at the facility, including specific forms to be used, how to use them and will train staff on the written plan and how to use the forms and how to inform child's authorized representative when administering medication to children. Licensee will send written plan and sign in sheet for staff trained to LPA Strother by 09/01/22.
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A review of C1's records indicates that the administration of medication given to C1 on 08/16/22 was not recorded. Staff interviewed had no knowledge of a written plan to do so, which poses a potential risk to the children in care.
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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: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/25/2022 07:46 PM - It Cannot Be Edited


Created By: Amy Strother On 08/25/2022 at 05:15 PM
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: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2022
Section Cited
CCR
101212(d)(1)(C)

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d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department...(1)Events reported shall include the following: (C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
This requirement was not met as evidenced by:
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Licensee stated that she will submit a written Unusual Incident Report to the Department regarding the incident that occurred on 08/16/22 were a child was given medication and had side effects observed by staff.
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The facility was made aware that C1 was given a additional dose of a 12 hour medication that C1 had received prior to arrival and side effects of the overdose of medication were observed by Staff and C1's parent. A review of records indicated that this incident was not reported to the Department as required, which poses a potential health, safety and personal rights risk to the children in care.
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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: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022


LIC809 (FAS) - (06/04)
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