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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483007424
Report Date: 08/14/2019
Date Signed: 08/14/2019 02:11:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:MUSTARD SEED PRESCHOOLFACILITY NUMBER:
483007424
ADMINISTRATOR:NOGALIZA, DANNIELLEFACILITY TYPE:
850
ADDRESS:901 SOLANO AVE.TELEPHONE:
(707) 557-7923
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY:42CENSUS: 28DATE:
08/14/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Dannielle Nogaliza and Jeanette Tongson-Assistant DirectorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Melchisedeck Augustin made a follow up inspection, in response to an unusual incident that occurred on 05/20/19 at 12:50pm, where a child (C1) fell off a play structure slide on the playground. The UIR specifies that C1 was being chased by another child (C2), C1 went half way down the slide and C1 fell off the outdoor slide. Community Care Licensing (CCLD) was not notified about the unusual incident within the Department's next working day and during its normal business hours. On 05/28/19, the facility submitted a UIR to the Department. During today's inspection, LPA met with Director Dannielle Nogaliza and LPA discussed the purpose of the inspection with the Director. At 11:23am, LPA conducted an interview with the Director, interviewed one staff (S1) at 12:03pm; and obtained a facility roster of the children currently in care. At 1:10pm, LPA conducted a telephone interview with one staff (S2). S1 and S2's statements were consistent in the occurrence of the incident. S1 and S2 claimed that C1 was playing a game of tag on the outdoor playground, C1 went on the outdoor slide, C1 walked half way down the slide and C2 pushed C1 off the slide. S2 claimed that she was supervising 10 or 11 children on the playground, the incident occurred quickly and S2 did not have time to intervene. S2 claimed during the incident, she was standing about six feet away from C1. At 11:23am, the Director claimed on 05/20/19 at approximately 12:50pm, C1 was playing on the outdoor playground with C2, C1 was walking down the outdoor small play structure slide and C2 pushed C1 off the slide. Director claimed that C1 fell off the slide, C1 landed on his left shoulder. Director claimed that C1 sustained a broken left collar bone as a result of the incident. Director claimed C1's parent was notified about the incident and she did not know that she was required to notify CCLD about the incident within the Department's next working day or business day. LPA consulted on CCR 101212 Reporting Requirements with the Director. LPA has determined that the unusual incident did not occur as a result of lack of or absence of supervision, however the facility failed to comply with Title 22 California Code of Regulation (CCR) 101212. LPA issued an Advisor Note for this Technical Violation. This report was discussed and reviewed with the Assistant Director. Notice of Site Visit shall be posted for 30 days from today's inspection. There were not Title 22 deficiency cited during today's inspection.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Melchisedeck AugustinTELEPHONE: (707) 494-4918
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
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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