304370239-4-5-2021-06-CC-CNGN-BZSTM7-20210405145041

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304370239
Report Date: 04/05/2021
Date Signed: 04/05/2021 02:50:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	GODDARD SCHOOL, THE		FACILITY NUMBER:	304370239
ADMINISTRATOR:	BISHOP, TIMOTHY		FACILITY TYPE:	850
ADDRESS:	1 AURA LANE		TELEPHONE:	(949) 218-6200
CITY:	LADERA RANCH	STATE: CA	ZIP CODE:	92694
CAPACITY:	158	CENSUS: 121	DATE:	04/05/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Executive Director, Ana Salinas		TIME COMPLETED:	11:30 AM

NARRATIVE

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Tele- Inspection Case Management Visit due to COVID-19 State of Emergency

Licensing Program Analyst (LPA) Cindy Nguyen conducted a case management inspection in response to a self reported incident. This is a continuation of the case management inspection on 3/24/21. LPA Nguyen notified the administrative that due to COVID-19 and Department of Public Health (DPH) guidelines of social distancing a Tele-Inspection would be conducted.

A FaceTime call was made with Executive Director, Ana Salinas. During the Tele-Inspection there were 10 toddlers belong to toddler option program with 2 staff in one room, 111 preschool age children, and 13 preschool staff. During today's tele-inspection it was determined that the facility was operating within the licensed capacity and within compliance of staffing ratios. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 03/05/21 the facility self reported that on 03/04/2021 Child#1 (C1) grabbed a toy from a small wooden shelf. While grabbing the toy C1 pushed on the shelf causing it tip over. The edge of the shelf landed on Child #2 (C2), injuring the big toe.

During the course of the investigation, LPA reviewed incident report and other documentation, interviewed staff, and conducted two tele-inspection. LPA also inspected the shelf. In the documentation & interviewed, Staff #1 (S1) witnessed the incident and was standing very close by. S1 quickly picked up the shelf and attended to C2. The wooden shelf is approximately 24”X35”X14”, was sturdy and had been stationed in the middle of the classroom separating the circle area and activities tables.

Continue to Page 2, LIC 809-C

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Cindy Nguyen	TELEPHONE: (714) 296-3608
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: GODDARD SCHOOL, THE	FACILITY NUMBER: 304370239
	VISIT DATE: 04/05/2021

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Page 2, LIC 809-C

Since the incident the wooden shelf has been moved up against the wall and is no longer in the middle of the classroom. At the time of the incident ratio were being met, present at the time were 2 staff and 12 children. Furniture was in good condition. Based on LPA observations, interviews which were conducted, and records/documentation reviewed, there is no evidence to support any violation of Title 22 regulations. No Title 22 deficiencies cited during today's inspection.

An exit interview was conducted with the Executive Director, Ana Salinas, via tele-inspection on this date. Appeal Rights were reviewed and explained. A copy of this report and Appeal Rights (LIC 9058 1/16) were emailed to the administrative. First level appeals should be sent to the Regional Manager to the address listed above. The administrative will email a received acknowledgement as her signature for this report due to the tele-inspection delivery by typing, “I have read and received the Evaluation Report, I acknowledge receipt” in the subject line of the return email.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Cindy Nguyen	TELEPHONE: (714) 296-3608
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

LIC809 (FAS) - (06/04)

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