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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455401376
Report Date: 09/28/2023
Date Signed: 09/28/2023 12:34:19 PM


Document Has Been Signed on 09/28/2023 12:34 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926



FACILITY NAME:SHASTA HEAD START - ANDERSON PARK CENTERFACILITY NUMBER:
455401376
ADMINISTRATOR:MILLER, SUSANFACILITY TYPE:
850
ADDRESS:1600 VETERANS LANETELEPHONE:
(530) 245-5118
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY:56CENSUS: 32DATE:
09/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Susan MillerTIME COMPLETED:
12:45 PM
NARRATIVE
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On 9/28/23 at 11:50 am a visit was conducted by Licensing Program Analyst's (LPA) Mendez in response to an unusual incident that was self-reported in a timely manner by Suzanne Miller, facility director. The incident occurred on 9/19/23 at approximately 9:03am. Community Care Licensing Division (CCLD) was notified within 24 hours and an unusual incident report was sent in writing within the 7 days as required. Facility director reported child (C1) was flailing arms and legs and that staff (S1) had removed the child and during the removal C1 had hit their head.

LPA Mendez conducted an interview with facility director Suzanne Miller at approximately at 9:54am on 9/25/23that S1 was trying to remove C1 who was being resistant and trying to pick C1 up from the ground. C1 was standing and slipped and hit their head. Director stated that there was no bump on C1’s head and C1’s parents received a copy of the ouch report.

SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: SHASTA HEAD START - ANDERSON PARK CENTER
FACILITY NUMBER: 455401376
VISIT DATE: 09/28/2023
NARRATIVE
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LPA interviewed 3 staff (S2-S4) on 9/25/23 and 9/28/23. LPA asked staff if they had witnessed the incident in which the 3 of 3 staff stated no they did not witness the incident occur.

LPA Mendez reviewed the camera footage that was consistent with the statement that S1 had grabbed C1 from under the arms and C1 hit the back of their head before being physically removed from the classroom to outside. Staff (S1) did not follow proper protocol when they physically removed C1 from the classroom which resulted in C1 falling and hitting their head.

The facility was toured inside and outside, and LPA observed 32 children in care.

The following violation of the California Code of Regulations, Tittle 22: Division 12 was observed: Persona Rights violation occurred resulting in child being physically grabbed resulting in hitting their head see LIC 809D.

Notice of Site Visit shall be posted for 30 days from today’s visit.

SUPERVISOR'S NAME: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/28/2023 12:34 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926


FACILITY NAME: SHASTA HEAD START - ANDERSON PARK CENTER
FACILITY NUMBER: 455401376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2023
Section Cited
CCR
101223(a)(3)

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101223(a)(3) Personal Rights
The licensee shall ensure that each child is accorded the following personal rights: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature
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Facility representative stated that S1 is no longer working at the facility. Facility representative stated they have a scheduled training with staff to discuss the teaching pyramid strategies.
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This requirement is not met as evidenced by: Based on incident reported to licensing and video footage, S1 physically grabbed C1 and removed them from the classroom which resulted in C1 hitting their head.
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Facility representative will discuss discipline policy with staff and then all children will have a signed LIC 9224.

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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: Megan AvilesTELEPHONE: (530) 895-5984
LICENSING EVALUATOR NAME: Bianca MendezTELEPHONE: (530) 895-4357
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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