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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009958
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:21:41 PM

Document Has Been Signed on 01/16/2025 02:21 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:CLOVERDALE EAGLETS PRESCHOOL & DAYCARE CENTERFACILITY NUMBER:
493009958
ADMINISTRATOR/
DIRECTOR:		BOEHM, JEANETTEFACILITY TYPE:
850
ADDRESS:530 NORTH CLOVERDALE BLVDTELEPHONE:
(707) 894-6037
CITY:CLOVERDALESTATE: CAZIP CODE:
95425
CAPACITY: 40TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
01/16/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Jeanette BoehmTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
NARRATIVE
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An unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Amy Strother regarding documents needed to approve the new Director’s qualifications. LPA met with Licensee, Jeanette Boehm (L1).

During today’s visit, no toddlers were present. 8 preschool age children were present, and napping supervised by L1 and 3 aides. The facility was operating within the licensed capacity and ratio requirements. L1 provided LPA with the following documentation during the visit: L1's Preventative Health and Safety for Child Care Providers course certificate, completed on 10/12/24. L1 was not able to provide LPA with the last document needed to approve L1 as the Director, a current Pediatric First Aid/CPR certificate, is still needed. LPA requested proof of another staff persons (S1-S3) proof of current pediatric First Aid/CPR certification for review. At 1:47pm L1 stated that no staff person present has a current pediatric First Aid/CPR Certificate.

The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC809 Deficiency page. This report was read and reviewed with Licensee, Jeanette Boehm. Appeal rights provided.

Notice of site visit shall be posted for 30 days.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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 01/16/2025 02:21 PM - It Cannot Be Edited


Created By: Amy Strother On 01/16/2025 at 01:59 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: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/14/2025
Section Cited
CCR
101216(f)

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(f) At least one staff member who is trained in pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safety Code Section 1596.866 shall be present when children are at the child care center or offsite for center activities.

This requirement was not met as evidenced by:
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Licensee stated that she and her staff will sign up for an approved Pediatric First Aid/CPR course, sending proof of current certificate to LPA Strother by 02/14/25.
amy.strother@dss.ca.gov
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Based on interview, Licensee stated at 1:47pm that no staff on site have a current Pediatric First Aid/CPR certificate, which poses a potential health and safety risk to 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:Megan Aviles
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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