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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010689
Report Date: 10/29/2024
Date Signed: 10/29/2024 03:36:04 PM

Document Has Been Signed on 10/29/2024 03:36 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:4CS PAULIN CREEK CHILD DEVELOPMENT CENTERFACILITY NUMBER:
493010689
ADMINISTRATOR/
DIRECTOR:		JENNY COPELANDFACILITY TYPE:
860
ADDRESS:905 MENDOCINO AVENUETELEPHONE:
(707) 565-3420
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 0DATE:
10/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Jenny CopelandTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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A prelicensing inspection was conducted today by Licensing Program Analyst (LPA), J. Snow. LPA met with facility representative Jenny Copeland for a change of location & conversion to single license. The old facility is 493005826 4CS PAULIN CREEK CDC - PRESCHOOL. The applicant/licensee is requesting a license for 24 preschool children age 2-5 years. The facility will operate Monday-Friday, 7am to 5:30pm. The facility has 2 rooms and one children’s bathroom & a staff bathroom.

The indoor and outdoor activity spaces were toured, and the facility sketch was verified. The kitchen will be off limits to children, made inaccessible by means of a gate. The staff and storage rooms will be made off limits by door locks. There is a Kitchen to store/prepare meals with a refrigerator, oven & dishwasher. Poisons are locked in a cabinet in the kitchen. Children will nap on cots in the classrooms. The isolation area for sick children will be located in the office.

The outdoor play area is fully fenced. No climbing structures, pool spa or body of water. The 4 stairs to the yard are barricaded at the top with a door. There is safe and age-appropriate furniture, toys, and play equipment available for children. A capacity worksheet was completed during the visit. Indoor square footage for the Blue and Yellow rooms are 931.5. The outdoor square footage is 2,871 plus 3 toilet/sinks for children. There is enough space for the requested capacity.

Facility representative 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. continued
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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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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: 4CS PAULIN CREEK CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 493010689
VISIT DATE: 10/29/2024
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (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.

LPA reviewed with facility representative the LIC 311A, Records to Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted. LPA discussed the safe sleep regulations with the facility representative and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep, as an additional resource. LPA also informed the facility representative of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Jenny Copeland 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.

Exit interview conducted and report was reviewed with the facility representative Jenny Copeland

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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

No additional corrections requested. The facility is licensed for 24 preschool, effective tomorrow, October 30,
2024.
SUPERVISORS NAME: Mai Lor
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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