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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 283005477
Report Date: 06/14/2019
Date Signed: 06/14/2019 12:34:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:CHILDREN'S COTTAGE - PRESCHOOLFACILITY NUMBER:
283005477
ADMINISTRATOR:TIFFANY KEARFACILITY TYPE:
850
ADDRESS:1078 EAST AVENUETELEPHONE:
(707) 224-3825
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY:64CENSUS: DATE:
06/14/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ray Welch, ownerTIME COMPLETED:
12:45 PM
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LPA Kevin O'Connell made an unannounced Case Management visit for an unusual incident that occurred on 6/13/19 where child Lochlan Carnes, C-1 (DOB 6/10/15) was kicking the ball back and forth on the playground with another child, Arthur Penders (DOB 2/24/13), C-2. C-1 twisted his leg while trying to kick the ball and fell to the ground. Teachers converged to help, applied ice, called Director. Parents were called, father arrived quickly. Father was previously an EMT. Father took C-1 to the Preschool classroom to assess C-1 and then transported him to the Kaiser in Vallejo. C-1 was transferred from Vallejo to Oakland Kaiser for surgery.
LPA spoke to Licensee who just received an update from Mother, Deborah Carnes 10:25am who told him that C-1 is doing okay. He had surgery 6/13/19 for a broken femur and was placed in a Sika cast (waist and one leg) for 6 weeks. He will return to care after the cast is removed per parents. Mother is a teacher and is off for the summer so she will take care of him until the cast is removed. There were 3 teachers on the playground at the time of the incident. The 3 teachers were interviewed and it was determined through interviews that the injury did not occur because of a lack of supervision.
LPA obtained UIR while at facilty.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019
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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