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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313621361
Report Date: 04/21/2022
Date Signed: 04/21/2022 01:56:37 PM


Document Has Been Signed on 04/21/2022 01:56 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:GODDARD SCHOOL, THE (PS)FACILITY NUMBER:
313621361
ADMINISTRATOR:HANNAH SIMMONSFACILITY TYPE:
850
ADDRESS:2021 WILDCAT BLVDTELEPHONE:
(916) 778-6620
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:132CENSUS: 87DATE:
04/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Hannah SimmonsTIME COMPLETED:
02:05 PM
NARRATIVE
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On April 21, 2022, Licensing Program Analyst (LPA) Jeremey McClain met with director Hannah Simons for an unannounced Case Management Inspection.

LPA observed a census of 87 preschool children supervised by 14 staff members in seven different rooms.

The purpose of today’s inspection was to follow up on an Unusual Incident that was reported by the facility on April 20, 2022. It was reported that a child was left inside the classroom alone during a transition to the outdoor playground. Video footage was reviewed today and shows that Staff #1 and #2 had closed the door after 22 children exited the classroom at 10:42 am. At 10:45 am, child #1 was observed leaving the classroom to approach staff #1 on the playground.
Type A Deficiency
LPA McClain informed director Hannah Simons that this report dated April 21st, documents one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care. Also, LPA McClain informed the licensee director Hannah Simons to provide a copy of this licensing report dated April 21st, 2021, that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
Posting Requirements
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

This report was reviewed with licensee, and an exit interview was conducted. Appeal Rights were provided.

A Notice of Site Visit was provided and should remain posted for 30 days.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Jeremey McClainTELEPHONE: (916) 216-7801
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
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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Document Has Been Signed on 04/21/2022 01:56 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833


FACILITY NAME: GODDARD SCHOOL, THE (PS)
FACILITY NUMBER: 313621361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/22/2022
Section Cited

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Responsibility and Providing Care and Supervision.(a) The licensee shall provide care and supervision as necessary to meet the children's needs.(1)No child(ren) shall be left without the supervision of a teacher at any time.Supervision shall include visual observation. This requirment was not met as evidenced by video review and an Unsual
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Incident Report that was submitted on 04/20/2022. Director reported that on 04/20/2022, child #1 was left alone in the Pre-K 2 classroom for three miniutes after Staff #1 and #2 transitioned 22 other children to the outside playground. This is an immediate risk to children in care if not corrected.
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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.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Jeremey McClainTELEPHONE: (916) 216-7801
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2022
LIC809 (FAS) - (06/04)
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