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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490101798
Report Date: 04/11/2022
Date Signed: 04/13/2022 10:46:53 AM


Document Has Been Signed on 04/13/2022 10:46 AM - 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:SPRING HILL MONTESSORIFACILITY NUMBER:
490101798
ADMINISTRATOR:HAMIDI, SHAHARAZADFACILITY TYPE:
850
ADDRESS:825 MIDDLEFIELD DRTELEPHONE:
(707) 763-9222
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:107CENSUS: 64DATE:
04/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Loryn HattenTIME COMPLETED:
03:30 PM
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While at the facility for another purpose, LPA conducted unannounced Case Management visit to follow up on an unusual incident reported by the facility via Unusual Incident Report (UIR) on 03/17/2022.
Per UIR, at 11:25 a.m. on 03/16/2022, a child (C1) slid down the tube slide on the playground, was helped up by another child (C2), and then was observed crying by a staff (S1). S1 observed C1 holding their left arm close to their body, provided ice and called the parent, who picked up the child and obtained medical assessment and treatment. Medical professional thought C1 had a fractured left wrist and put on a soft cast, but follow up x-rays showed no fracture. C1 stayed home for two days and returned to school after the Spring break.

During today's visit, LPA toured the outdoor play area and did not observe any hazards that could have caused this injury. LPA interviewed S1, S2, C1, and C2. This incident was reported to Community Care Licensing as required. This report was read and reviewed with the center director. There were no Title 22 deficiencies cited during today's inspection.
Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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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