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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233004124
Report Date: 06/05/2025
Date Signed: 06/05/2025 11:26:04 AM

Document Has Been Signed on 06/05/2025 11:26 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BROOKSIDE PRESCHOOLFACILITY NUMBER:
233004124
ADMINISTRATOR/
DIRECTOR:		CHELSEA RODRIGUEZFACILITY TYPE:
850
ADDRESS:SPRUCE AND LINCOLN WAYTELEPHONE:
(707) 459-5385
CITY:WILLITSSTATE: CAZIP CODE:
95490
CAPACITY: 20TOTAL ENROLLED CHILDREN: 23CENSUS: 0DATE:
06/05/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:32 AM
MET WITH:Chelsea RodriguezTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
NARRATIVE
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A Case Management visit was conducted at the facility by Licensing Program Analyst (LPA) Robert Maciel in response to a self-reported Unusual Incident Report received by the department on 05/23/25 regarding a child (C1) who was left on the playground during transition inside. LPA met with Site Supervisor Chelsea Rodriguez (D1).

According to the incident report and interviews conducted, at around 1:35 PM on May 23, 2025, facility staff were transitioning children from the outdoor playground to the classroom. Staff counted 8 children in total and had them line up to prepare to go inside the classroom. While in line, there was an altercation between two children which drew the attention of staff and, during this time, another child (C1) in the back of the line returned to the playground. After staff and children had entered the classroom, staff noticed there was a child missing and began recounting to verify. A teacher from the NCO Head Start facility (#230111196) observed the child in the playground and returned them to the classroom. D1 stated that the child was outside for less than 2 minutes. D1 stated that staff will now perform a second head count during transition after children line up to prevent this situation from occurring again.

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. Failure to do so shall result in an immediate civil penalty of $100.
NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Robert Maciel
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/05/2025 11:26 AM - It Cannot Be Edited


Created By: Robert Maciel On 06/05/2025 at 11:16 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKSIDE PRESCHOOL
FACILITY NUMBER: 233004124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2025
Section Cited
CCR
101229(a)(1)

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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:
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Site Supervisor (D1) stated that she has already implemented a policy in which children, during transiiton, are double counted before entering the classroom to verify that no children have left the line. D1 submitted a written statement confirming that policy to LPA.
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Based on an unusual incident report and staff statement, a child (C1) was left outside in the facility playground which poses an potential health & safety risk to 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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Robert Maciel
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2025


LIC809 (FAS) - (06/04)
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