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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053608891
Report Date: 09/03/2019
Date Signed: 09/03/2019 01:38:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:RESOURCE CONNECTION OF AMADOR&CALAVERAS,MURPHYSFACILITY NUMBER:
053608891
ADMINISTRATOR:KAMDROGRUB, KOMOLFACILITY TYPE:
850
ADDRESS:196 PENNSYLVANIA GULCH RD.TELEPHONE:
(209) 728-9946
CITY:MURPHYSSTATE: CAZIP CODE:
95247
CAPACITY:20CENSUS: 1DATE:
09/03/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Komol KamdrogrubTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Justin Denton met with Site Supervisor Komol Kamdrogrub to discuss the an unusual incident report that was reported to Community Care Licensing (CCL) on 06/7/19.

During today's inspection, LPA observed the facility and interviewed Site Supervisor Kamdrogrub about an incident which occurred on 5/30/19. Information obtained during the interview revealed that Child 1 (C1) was left outside on the playground for about 3-4 minutes. C1 was hiding under a slide after a disagreement with a peer when Staff 1 (S1) brought the other seven children on the playground inside.

This is a violation of Title 22 Section 101229(a)(1) and will be cited. Immediate civil penalty will be assessed.

Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.

Deficiencies issued during today's case management incident visit. Notice of Site visit posted and exit interview conducted.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2019
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: RESOURCE CONNECTION OF AMADOR&CALAVERAS,MURPHYS
FACILITY NUMBER: 053608891
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2019
Section Cited

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Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). This requirement was not met as evidenced by:

Staff and management admitted that a child
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was left on the playground alone during transitioning (from outside to inside). Child was left alone with no supervision for approximately 3 to 4 minutes.
This is an immediate risk to the health and safety of 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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Justin L DentonTELEPHONE: (916) 926-9269
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2019
LIC809 (FAS) - (06/04)
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