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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313621361
Report Date: 12/16/2022
Date Signed: 12/16/2022 12:20:52 PM


Document Has Been Signed on 12/16/2022 12:20 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: 101DATE:
12/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Hannah SimmonsTIME COMPLETED:
12:25 PM
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On December 6th, 2022, Licensing Program Analyst (LPA) Jeremey McClain met with Licensing Representative Hannah Simons for an unannounced Case Management Inspection regarding an Unusual Incident Reported.

LPAs observed care and supervision of 101 preschool and toddler aged children by 14 staff between seven different classrooms.

On Decemeber 5th, 2022, it was reported that a child hit their chin on the steps of a play structure outside on the playground. The wound was cleaned and a band aid and ice was applied by staff. The child later received stitches after being taken to care. LPA made observations to the playground and equipment. LPA spoke with staff regarding the incident.

LPA determined that the incident was not due to lack of supervision or hazards on the playground. No deficiencies were observed.

This report was reviewed with the Licensing Representative. LPA provided a Notice of Site Visit, which must 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: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022
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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