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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010661
Report Date: 09/26/2024
Date Signed: 09/26/2024 04:16:49 PM

Document Has Been Signed on 09/26/2024 04:16 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: 19DATE:
09/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH: Jessica BorlandTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 09/26/2024, Licensing Program Analysts (LPA), Sebastian Phouthaovong made an unannounced Case Management visit in response to a self-reported Unusual Incident Report (UIR). UIR was notified to Community Care Licensing on 09/12/2024. The incident was regarding a child escaping from the premise and reaching the area across the parking lot. The child was manly viewed by staff during this incident. LPA met with Director, Jessica Borland and spoke with her the purpose of today's visit.

During today's inspection, LPA toured the facility inside and out and observed 19 children being supervised by 6 staff members. LPA conducted interviews with the Director and four staff members. Director and staff informed Licensee of the facility’s procedure on how the facility will ensure that proper supervision is being applied and that the daycare children are in a safe and healthy environment.

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 Staff, Jennifer Peterson.

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

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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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