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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343620246
Report Date: 07/18/2022
Date Signed: 07/18/2022 12:24:36 PM


Document Has Been Signed on 07/18/2022 12:24 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:
343620246
ADMINISTRATOR:FERGUSON, JAMIEFACILITY TYPE:
830
ADDRESS:251 OUTCROPPING WAYTELEPHONE:
(916) 936-0377
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:24CENSUS: 15DATE:
07/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jamie Ferguson and Kaylee AgamanTIME COMPLETED:
12:45 PM
NARRATIVE
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On Monday July 18th, 2022, Licensing Program Analyst (LPA) Kelly Ferrara conducted a Case Management Inspection and met with Director Jamie Ferguson and Owner Kaylee Agaman. Today's census included 15 infant children in care with four staff.

LPA Ferrara received an Unusual Incident Report from the facility regarding an incident that occurred with an infant on July 14th, 2022. During today's inspection to follow up on the incident, LPA interviewed Director and staff. LPA observed the children in care and received relevant documentation.

Based on the information received, the facility staff handled the incident appropriately. One type B citation has been issued regarding documentation of sleep checks conducted every 15 minutes.

Exit interview was conducted and a copy of this report was given to the Director. Notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
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 07/18/2022 12:24 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: 343620246

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2022
Section Cited

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Responsibility for Providing Care and Supervision for Infants. Staff shall physically check on sleeping infant(s) every 15 minutes and document the following: Labored breathing. Signs of distress, which includes but is not limited to flushed skin color, increase in body temperature and restlessness........
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This requirement was not met as evidenced by: LPA observed that the facility was not documenting infant sleep in the 12-18 month old classroom. This is a potential health and safety risk to 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: Natalie DunawayTELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Kelly FerraraTELEPHONE: (916) 425-5932
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2022
LIC809 (FAS) - (06/04)
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