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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623141
Report Date: 02/27/2020
Date Signed: 02/28/2020 03:09:57 PM

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:CREATIVE SPIRIT LEARNING CENTERFACILITY NUMBER:
343623141
ADMINISTRATOR:BRANN, NICOLEFACILITY TYPE:
850
ADDRESS:10729 FAIR OAKS BLVDTELEPHONE:
(916) 967-7883
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:24CENSUS: DATE:
02/27/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Nicole BrannTIME COMPLETED:
02:30 PM
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This is an amended document

Licensing Program Analysts Lea Habtom and Katrina Owens met with director Nicole Brann to follow up on an incident that occurred on January 17, 2020 reported by the director.

A census was taken which included 19 preschool children supervised by 4 staff.

LPA's interviewed director Nicole Brann who stated at 1:45pm child, 3 years old, was putting paperwork up on a couch and started to jump on the couch when teacher Ms. Krystal asked the child to get down. The child lost balance and as the child was coming down the child hit the back of the head on the light table. At the time of the incident Ms. Amy & Ms. Brianna were in the classroom. Ms. Krystal brought the child over to the director Nicole who applied an ice pack & a clean cloth to clean up the small amount of blood from the injury. The child's mother was called and the child was picked up from school before the day was over at 3:45pm. That evening the child's mother notified the director the child required medical attention which resulted in staples. The child returned to school the following Friday on January 24, 2020 with a schedule of Monday, Wednesday and Friday.

Following the incident the couch was later removed from the classroom and placed outdoors.

Based on the interview conducted LPA concluded that there were no title 22 violations as the facility had proper supervision, 3 teachers, in the vicinity. The toys and equipment do not appear to be a danger to children in care.


SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
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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