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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010661
Report Date: 08/26/2024
Date Signed: 08/26/2024 03:40:39 PM

Document Has Been Signed on 08/26/2024 03:40 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 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: 11DATE:
08/26/2024
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH: Facility Representative, Jessica BorlandTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 08/26/2023, Licensing Program Analysts (LPAs), Sebastian Phouthaovong and Glenn Ouye made an announced Case Management visit and met with Facility Representative, Jessica Borland to review the facility's daily operation and to review Community Care Licensing Requirements.

During today's inspection, LPAs toured the facility inside and out and observed 11 children being supervised by 4 staff members. Care and supervision will be provided in Classroom 7A, which incudes two bathrooms for day care children. There is one outdoor activity play space on the property that is used by the preschool program and is fully fenced. The facility was approved a shared outdoor play waiver that indicated that the programs would not commingle and utilize the yard at separate times. Facility Representative reviewed that the waiver shall be posted.

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.

Exit interview conducted and report was reviewed with Facility Representative, Jessica Borland.

There were no Title 22 deficiencies cited during today's inspection.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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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