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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 233009652
Report Date: 05/28/2025
Date Signed: 05/28/2025 04:19:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2025 and conducted by Evaluator Robert Maciel
COMPLAINT CONTROL NUMBER: 01-CC-20250520150306
FACILITY NAME:POLLIWOG PLAYSCHOOLFACILITY NUMBER:
233009652
ADMINISTRATOR:RICCA, WANDAFACILITY TYPE:
850
ADDRESS:19201 DEL MAR DRIVETELEPHONE:
(707) 961-0874
CITY:FORT BRAGGSTATE: CAZIP CODE:
95437
CAPACITY:45CENSUS: 36DATE:
05/28/2025
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Elizabeth ReyesTIME COMPLETED:
04:29 PM
ALLEGATION(S):
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Facility is operating out of ratio

Facility staff are not properly qualified
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Robert Maciel made an unannounced Complaint Investigation visit and met with the Facility Representative, Elizabeth Reyes (S4). LPA initiated the investigation by discussing the purpose of the visit, conducting interviews with Licensee and staff; reviewed facility records, and made observations. It is alleged that the facility is operating out of ratio and that facility staff are not properly qualified.

During today's visit, LPA observed 36 children being supervised by 4 staff. At 1:50 PM, LPA observed that staff 5 (S5) was supervising 12 children in the art room by herself. Review of S5's staff record of qualifications revealed that S5 is only qualified as an aide, corroborating the allegations.

Based on the evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal rights were provided and exit interview conducted. The Notice of Site Visit must be posted for 30 days.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melchisedeck Augustin
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 01-CC-20250520150306
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: POLLIWOG PLAYSCHOOL
FACILITY NUMBER: 233009652
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/04/2025
Section Cited
CCR
101216.2(e)
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(e) An aide shall work only under the direct supervision of a teacher.

This requirement was not met as evidenced by:
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Licensee stated that she would ensure S5 enrolls in at least 2 units for the summer semester by 6/4/25 and send proof of enrollment to LPA by email at robert.maciel@dss.ca.gov.
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Based on LPA observation and file review, staff 5 (S5) was supervising 12 children in the art room by herself and did not possess teacher qualifications.
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Type B
06/04/2025
Section Cited
CCR
101216.3(a)
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(a) There shall be a ratio of one teacher visually observing and supervising no more than 12 children in attendance, except as specified in (b) and (c) below.

This requirement was not met as evidenced by:
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Licensee stated that she would ensure S5 enrolls in at least 2 units for the summer semester by 6/4/25 and send proof of enrollment to LPA by email at robert.maciel@dss.ca.gov.
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Based on LPA observation and file review, staff 5 (S5) was supervising 12 children in the art room by herself and did not possess teacher qualifications.
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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.
SUPERVISORS NAME: Melchisedeck Augustin
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2