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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393605862
Report Date: 11/03/2023
Date Signed: 11/03/2023 02:15:50 PM


Document Has Been Signed on 11/03/2023 02:15 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:CATALYST KIDS - JACOBSONFACILITY NUMBER:
393605862
ADMINISTRATOR:MALISSA MASTROPIERROFACILITY TYPE:
850
ADDRESS:1750 KAVANAGH STREETTELEPHONE:
(209) 832-8799
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:48CENSUS: 11DATE:
11/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Andiana SerranoTIME COMPLETED:
02:35 PM
NARRATIVE
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On November 3, 2023, Licensing Program Analyst (LPA) Stacey Williams arrived at the facility for the purpose of conducting a case management inspection. LPA met with Program Lead, Andiana Serrano. LPA observed (11) eleven children supervised by four staff.

On November 2, 2023, Community Care Licensing was notified of an incident involving a lack of supervision for children in care. It was reported that while dismantling after a staff meeting, a staff member (S1) designated to supervise children during the napping period used the restroom. While in the restroom, the remaining staff in the center left to go on breaks and prepare for the start of the school age program. Interviews conducted revealed that staff did not hear S1 inform them of her stepping away to use the restroom. There was an estimated time period of less than one minute that children in care were left unsupervised.

Based on the information received, Title 22 deficiencies will be cited on subsequent page, LIC 809D.

Exit interview conducted and report was reviewed with Facility Representative, Andiana Serrano. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
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 11/03/2023 02:15 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: CATALYST KIDS - JACOBSON
FACILITY NUMBER: 393605862

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2023
Section Cited
CCR
101229(a)(1)

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Responsibility for 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, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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Program Lead stated that all staff will be trained in the area of supervision through modules and review of Title 22 Regulations. New protocols will be implemented to incorporate face to name acknowledgement when staff is stepping away from providing care.
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This requirement was not met as evidenced by: Children in care were left unsupervised for less than one minute while staff used the restroom. This is an immediate risk to the health and safety of children in care.
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Documentation of training, summary of new protocol and meeting roster will be submitted to CCL by POC date- 11/17/23.

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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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Stacey WilliamsTELEPHONE: (916) 216-7797
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2