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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343615181
Report Date: 02/08/2023
Date Signed: 02/08/2023 12:01:43 PM


Document Has Been Signed on 02/08/2023 12:01 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, THEFACILITY NUMBER:
343615181
ADMINISTRATOR:LEE, KATELYNNFACILITY TYPE:
850
ADDRESS:10710 BEAR HOLLOW DRIVETELEPHONE:
(916) 861-0906
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:108CENSUS: 88DATE:
02/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Katelynn LeeTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christopher Bello arrived at the facility at approximately 11:30am and met with director Katelynn Lee, regarding an Unusual Incident that took place January 20, 2023. A daycare child was left alone in the playground without adult supervision for approximately two minutes. The facility self-reported the incident to the department and notified the child's parent of the incident. Director stated that they have retrained staff on name to face procedures. They are also making a new “check” system to ensure moving forward that an incident like this will not occur again.

Title 22 Deficiencies have been cited on the attached LIC 809D. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Christopher BelloTELEPHONE: (916) 862-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
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 02/08/2023 12:01 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
FACILITY NUMBER: 343615181

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2023
Section Cited

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No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement has not been met by evidence: Daycare child was left alone without adult supervision for
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The facility self-reported the incident and notified the daycare child's parent. The facility also retrained staff to ensure an incident like this will not occur again. LPA cleared the deficiency.
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approximately 2 minutes. This is considered as an immediate risk to the children in care,
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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: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Christopher BelloTELEPHONE: (916) 862-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2023
LIC809 (FAS) - (06/04)
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