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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480105679
Report Date: 01/18/2024
Date Signed: 01/18/2024 12:20:14 PM


Document Has Been Signed on 01/18/2024 12:20 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:VUSD-CDC-FEDERAL TERRACE P/SFACILITY NUMBER:
480105679
ADMINISTRATOR:TRUJILLO,MARISAFACILITY TYPE:
850
ADDRESS:415 DANIEL AVENUETELEPHONE:
(707) 556-8755
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:30CENSUS: 7DATE:
01/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Monique GarciaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Glenn Ouye met with Site Supervisor, Monique Garcia and teacher Rachel Sameniego regarding a self reported unusual incident which occurred on 12/18/23. During the incident, a parent was on site to pick up the child, and the child became unresponsive. The parent thought that the child was choking and had something in the child's mouth. Staff acted quickly to assess the child and perform the Heimlich maneuver on the child. The child then became responsive and the paramedics arrived and took over the care for the child. The parent went with the child to the ER. Staff asked the parent to have child checked to determine if there was other medical issues but to their knowledge the child was not tested for other medical concerns. Staff observed that the child's jaw was clenched when child appeared non-responsive to parent speaking to child. The child was held out of program after incident and returned on 1/16/2024. The parent had communicated over the phone with staff indicating that the child was fine prior to returning. The child behavior and activity is at baseline.

The staff responded quickly and appropriately to address the needs of the child during the incident. They also called for emergency services which allowed the paramedics to arrive very quickly.

No deficiencies cited during the visit.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Glenn OuyeTELEPHONE: (707) 588-5042
LICENSING EVALUATOR SIGNATURE:
DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/18/2024
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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