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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173002941
Report Date: 08/14/2019
Date Signed: 08/14/2019 11:42:02 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:KELSEYVILLE MIGRANT HEAD START-INFANTFACILITY NUMBER:
173002941
ADMINISTRATOR:FLORES, PATRICIAFACILITY TYPE:
830
ADDRESS:5081 A KONOCTI ROADTELEPHONE:
(707) 279-1022
CITY:KELSEYVILLESTATE: CAZIP CODE:
95451
CAPACITY:32CENSUS: 7DATE:
08/14/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Patricia FloresTIME COMPLETED:
11:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Chris Arnhold arrived to this facility unannounced to conduct a case management visit in regards to an incident that occurred on 08/12/2019. LPA met with Director Patricia Flores, toured the facility and reviewed documents. The Director told LPA a child had taken a piece of garbage from the closed garbage can and attempted to place it in their mouth. The teacher attempted to remove the garbage from the child's hand, and the child tried to fall to the ground while the teacher was holding their hand. The teacher did not let the child fall. This incident happened at the end of the day. When the family arrived to pick up the child, they were advised of the incident and recommended they may want to have the child examined by a physician. The facility received physician documentation on 08/14/2019, showing the child was fine to return to school. Based on a review of records and interviews conducted, the teacher reacted appropriately when attempting to stop the child from eating the garbage. The child's reaction to being caught was to start crying and attempt to drop to the ground while the teacher was trying to remove the item.
LPA received copies of documents.
Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5056
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
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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