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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111876
Report Date: 02/03/2022
Date Signed: 02/17/2022 01:56:21 PM


Document Has Been Signed on 02/17/2022 01:56 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/10/2022 11:01 AM

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

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A Case Management visit was conducted at the facility by LPA Trinh in response to an Unusual Incident Report received January 07, 2022. LPA Trinh met with Director, Sara Barron (D1). LPA Trinh interviewed Staff 1 (S1) at 11:20 am. According to the incident report and interviews conducted, at 11:55 am on January 07, 2022, a 4 year old child (C1) was reported to have ran out of line going from Classroom 1 to Classroom 2. C1 ran to the front of the playground gate where he can be seen from Classroom 2. Playground is fully fenced and the classrooms are located within the fenced area.
Interviews support that it was about 30 seconds to one minute that C1 ran from Classroom 1 to the front of the playground gate. Interviews corroborate C1 was returned to his group and Teacher at 11:56 am.
During today’s visit there were 18 children accounted for and being supervised by 4 teachers. Based on available information, it has been determined that preschool staff were properly supervising C1 when the incident occurred on January 07, 2022.
*This report is amended to remove lack of supervision language because it did not occur and no citation issued.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Mary TrinhTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2022
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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