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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010661
Report Date: 08/15/2024
Date Signed: 08/15/2024 11:16:53 AM

Document Has Been Signed on 08/15/2024 11:16 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MATTIE WASHBURN DISTRICT PRESCHOOLFACILITY NUMBER:
493010661
ADMINISTRATOR/
DIRECTOR:		JESSICA BORLANDFACILITY TYPE:
860
ADDRESS:75 PLEASANT AVENUETELEPHONE:
(707) 837-7705
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 0DATE:
08/15/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Jessica BorlandTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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During today's visit, Centralized Application Bureau (CAB) Licensing Program Analyst (LPA) Arianna Manabat met with the Licensee Representative Jessica Borland for the purpose of an announced pre-licensing inspection. The Applicant is requesting to serve 24 preschool children ages two years to entry into kindergarten during the hours of Monday through Friday from 7:30am - 5:30pm. The facility is located on the Mattie Washburn elementary school campus and is using room 7A.

The facility's policy for food service is that the facility will be providing lunch, morning, and afternoon snacks. The facility will allow parents to bring/donate snacks to the facility. Additionally, LPA reviewed the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted with the facility representative.

INDOOR ACTIVITY SPACE:
There is one classroom being used on site and LPA Manabat observed that appropriate preschool supplies were currently displayed in each classroom. The facility representative was reminded that any items that need to have teacher supervision, such as age appropriate scissors, should be stored inaccessible to children until ready to use. There are first aid kits located in each classroom. Any medications will also be stored inaccessible to children. The facility representative stated that medications that need to be refrigerated will stored in the office area's refrigerator. LPA observed cleaning disinfectants are appropriately stored and inaccessible to children

The Applicant stated there are no poisons, bodies of water, or firearms on the premises. LPA Manabat discussed the importance of storing any poisons in a locked area with either a combination or a key lock.
LPA observed a functional carbon monoxide detector and fire extinguisher. LPA observed that the facility has a paper sign-in/sign-out sheet system. Water will be provided to the classroom via water bottles and will be refilled at the outdoor sink. Report continues on LIC809-C...
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MATTIE WASHBURN DISTRICT PRESCHOOL
FACILITY NUMBER: 493010661
VISIT DATE: 08/15/2024
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INDOOR MEASUREMENTS:
LPA measured the indoor classroom space during today's visit. The classroom space contains a total of 868.14 square feet, which will accommodate Applicant's request for 24 preschool children. There are 2 toilets and 2 sinks located in the facility. Staff restrooms are located on the elementary school campus, separate from children's. Individual measurements are recorded on the Capacity Worksheet (LIC 9024). Children who become ill during the day will be isolated in the nurses office with a staff member. There will be a mat available in this space.

OUTDOOR ACTIVITY SPACE:
There is one outdoor activity play spaces on the property that is used by the preschool program. During today's pre-licensing inspection, LPA Manabat observed that children from the elementary school were utilizing the play yard. After discussing that there would need to be an isolated outdoor play space available for the preschool program, LPA recommended that the applicant apply for a shared outdoor play waiver that indicated that the programs would not commingle and utilize the yards at separate times. LPA notified the facility representative that this would need to be a written request sent to the regional office.

The outdoor play areas are fenced with a chain-linked fence that are at least four feet tall. During today's visit, LPA observed that the outdoor play space did not have a play structure. LPA Manabat advised the facility representative that they would need to notify the Santa Rosa case carrying LPA prior to any construction that would to occur on the site. Additionally, LPA noted that shade was provided via trees, canopies, and overhangs of the building. Water outside is provided via a water fountain. There is a sufficient amount of equipment and toys and additional equipment stored in an outside shed. The Licensee Representative stated that the shed remains locked throughout the day and that selected staff have access to the lock.

Measurements were taken for the outdoor space footage and measured the outdoor activity space. The outdoor play area contains a total of 18,295 square feet, which will accommodate the requested capacity of 24 preschool children. Individual measurements are recorded on the Capacity Worksheet (LIC 9024).

Report continues on LIC809-C.
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MATTIE WASHBURN DISTRICT PRESCHOOL
FACILITY NUMBER: 493010661
VISIT DATE: 08/15/2024
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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226.The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

LPAs discussed the following: 100% supervision is required at all times, including in the bathroom; personal rights; inspection authority; reporting requirements; staff to children ratios and capacity; staff qualifications; and maintaining buildings and grounds. LPAs discussed with Applicant any changes that may occur regarding the director or an employee acting in the director's absence must be reported to department within 10 working days.

Applicant was reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California

Report continues on LIC809-C
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MATTIE WASHBURN DISTRICT PRESCHOOL
FACILITY NUMBER: 493010661
VISIT DATE: 08/15/2024
NARRATIVE
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP)

The following items are required before a license will be issued:

1. Manager approval
2. A written outdoor shared space waiver request.

Exit interview conducted and report was reviewed with the Licensee Representative. The facility representative understands and acknowledges that any advertising for the facility should include their facility (license) number.
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MATTIE WASHBURN DISTRICT PRESCHOOL
FACILITY NUMBER: 493010661
VISIT DATE: 08/15/2024
NARRATIVE
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SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5