153808447-11-10-2021-04-CC-JYAZ-C8MVGK-20211110152539

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 153808447
Report Date: 11/10/2021
Date Signed: 11/10/2021 03:25:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	A GOOD TIME OUT		FACILITY NUMBER:	153808447
ADMINISTRATOR:	MELANIE SHERMAN		FACILITY TYPE:	830
ADDRESS:	3400 CALLOWAY DRIVE, SUITE 502		TELEPHONE:	(661) 410-8463
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93312
CAPACITY:	17	CENSUS: 12	DATE:	11/10/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Amy Bennett		TIME COMPLETED:	03:40 PM

NARRATIVE

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On 11/10/2021, Licensing Program Analysts (LPAs) Jeovanna Yanez and Jessika Thompson conducted an unannounced case management inspection. LPAs toured the facility and a census was taken. LPAs met with Director, Amy Bennett. The purpose today's inspection was to discuss an incident that occurred on 10/21/21, in which staff #1 was terminated from the facility for causing an injury to child #1. This incident was reported to the Fresno Community Care Licensing Office on 10/21/21 by Director, Amy Bennett.

During today's inspection, information obtained revealed that staff #1 was holding child #1 under her arms while child’s feet were touching the floor. Staff #2 advised staff #1 that she would be moving from the Infant room to the Preschool room. At that point, staff #1 released child #1 from her grip who then fell head first onto the floor. Staff #1 allegedly did not show any concern for child #1 and then walked out of the Infant classroom. Staff #2 observed the incident and immediately scooped up child #1 to assess for any injuries. Child #1 had sustained a fairly large goose egg on the right side of her forehead. Staff #2 applied an ice pack to child and an Ouch report was reviewed and given to Child #1's parents. Staff #2 immediately notified Director of the incident. Director talked with staff #1 about her demeanor and video footage was reviewed confirming the incident occurred. Director sent staff #1 home for the rest of the day. Staff #1 was terminated on 10/20/21. Child #1 parent never made a complaint about any incidents, nor have any other parents.

Director acknowledged that as a result of staff #1 actions, the personal rights of children in care were violated. This poses an immediate risk to the health, safety, or personal rights of children in care.

Per Title 22, Division 12, Chapter 1, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D) Exit interview conducted with Director, Amy Bennett and a copy of appeal rights was provided.

CONTINUED ON 809-C

SUPERVISOR'S NAME: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jeovanna Yanez	TELEPHONE: (559) 341-5629
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: A GOOD TIME OUT	FACILITY NUMBER: 153808447
	VISIT DATE: 11/10/2021

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Upon receipt of a Type A violation, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. A copy of the Fact Sheet - Child Care Parent Notification Requirements and a copy of LIC 9224 was given to licensee.

This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jeovanna Yanez	TELEPHONE: (559) 341-5629
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

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, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: A GOOD TIME OUT	FACILITY NUMBER: 153808447
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/24/2021 Section Cited	1 2 3 4 5 6 7	Personal Rights (a) The licensee shall ensure that each child is accorded the following personal rights (1) To be accorded dignity in his/her personal relationships with staff ... This requirement is not met as evidenced by staff interview. Staff #1 caused a head injury to child #1.
	8 9 10 11 12 13 14	This poses an immediate risk to the health, safety or personal rights of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Diana deLeon	TELEPHONE: (559) 650-7854
LICENSING EVALUATOR NAME: Jeovanna Yanez	TELEPHONE: (559) 341-5629
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021

LIC809 (FAS) - (06/04)

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