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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 085406278
Report Date: 11/08/2023
Date Signed: 11/08/2023 11:44:25 AM


Document Has Been Signed on 11/08/2023 11:44 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
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926



FACILITY NAME:HEAD START - PINE GROVEFACILITY NUMBER:
085406278
ADMINISTRATOR:RAMIREZ, DORAFACILITY TYPE:
850
ADDRESS:900-A PINE GROVE ROADTELEPHONE:
(707) 465-6737
CITY:CRESCENT CITYSTATE: CAZIP CODE:
95531
CAPACITY:20CENSUS: 14DATE:
11/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Cally HuffTIME COMPLETED:
12:00 PM
NARRATIVE
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LPAs K. Lynch and N. Wheeler went to the facility for the purpose of an unusual incident report case management visit self-reported by the facility on 10/27/23. LPAs met with the Center Director Cally Huff, conducted an interview, observed care and supervision provided by staff to children, and toured the site of the incident. She stated a child was able to exit the site playground into the adjacent preschool/kindergarten playground site through an improperly latched gate due to organic leaf and dirt material which had built up in the ground latch hole. She stated the staff were supervising the child along with other children playing on the climbing/slide play structure outside, and the child was able to get to the gate and open it and go through into the next-door playground. She stated the child was unsupervised for less than a minute and was found by the State Preschool staff next door right by the gate and was brought back onto the site playground immediately afterwards. She stated the Licensee, Northcoast Children’s Services administrators and staff came out to the facility to clean/repair the gate, so it was able to be latched properly, and also conducted a diligent supervision refresher training with staff. LPAs observed appropriate care and supervision provided to children by staff at the time of the visit. LPAs observed the gate in question at the facility and observed it was fixed and in working order, and observed the other gates were as well. LPAs also observed staff participation diligent training documentation at the site. See next page for deficiency cited. Exit interview conducted with Center Director Cally Huff, notice of site visit posted, appeal rights provided.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 966-0216
LICENSING EVALUATOR NAME: Kiriko LynchTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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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Document Has Been Signed on 11/08/2023 11:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: HEAD START - PINE GROVE

FACILITY NUMBER: 085406278

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2023
Section Cited
CCR
101229

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Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the children's needs.
(1) No child(ren) shall be left without the supervision of a teacher at any time,
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Center Director stated Licensee NCS staff fixed the gate and also stated they also conducted a dilligent supervision training with staff. POC cleared at the time of the visit.
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except as specified in Sections 101216.2(e)(1)
(1) Supervision shall include visual observation. This requirement was not met as evidenced by a child was able to leave the site playground into the next-door playground. Facility staff self reported the incident to Licensing per Title 22 regulations.
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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: Erin VirruetaTELEPHONE: (530) 966-0216
LICENSING EVALUATOR NAME: Kiriko LynchTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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