<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233004124
Report Date: 12/14/2023
Date Signed: 12/14/2023 01:13:02 PM


Document Has Been Signed on 12/14/2023 01:13 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:BROOKSIDE PRESCHOOLFACILITY NUMBER:
233004124
ADMINISTRATOR:MELANIE HERNANDEZFACILITY TYPE:
850
ADDRESS:SPRUCE AND LINCOLN WAYTELEPHONE:
(707) 459-5385
CITY:WILLITSSTATE: CAZIP CODE:
95490
CAPACITY:20CENSUS: 12DATE:
12/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Chelsea RodriguezTIME COMPLETED:
10:53 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
A Case Management visit was conducted at the facility by Licensing Program Analyst (LPA) Robert Maciel in response to an Unusual Incident Report received December 12, 2023 involving a lack of supervision. On 12/14/23, LPA met with Site Supervisor Chelsea Rodriguez (S1). According to the incident report and interviews conducted, at around 1:20 PM on December 11, 2023, facility staff were transitioning children from the outdoor playground to the classroom. The number of present children at the facility was tallied at 10 but due to a late child entering the facility and the head count not being updated, an 11th child, C1, was not assembled in line to enter the facility. Faciltiy staff believed they had assembled all children currently in care and did not see C1. C1 was at the time hiding in the playground when children and staff entered the classroom. At around 1:20 PM to 1:30 PM, a staff member (A1) from the adjacent child care center, NCO Head Start Willits, that shares the playground with the Brookside Preschool noticed C1 in the playground sitting on a bench and brought them into the Brookside Preschool classroom. Based on available information, it has been determined that day care staff were not properly supervising the children when the incident occurred on December 11th, 2023.

The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. Appeal rights were provided.

Report was reviewed and read to the Site Supervisor Chelsea Rodriguez.
A notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 12/14/2023 01:13 PM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: BROOKSIDE PRESCHOOL
FACILITY NUMBER: 233004124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/28/2023
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Site Supervisor stated that she would implement multiple headcounts of children throughout the day spoken out loud and scan the playground visually before transitioning to ensure the accurate tally of children currently in care.
8
9
10
11
12
13
14
Based on an unusual incident report and staff statement, a child was left outside in the facility playground which poses an potential health & safety risk to children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Robert MacielTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2