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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490103579
Report Date: 11/08/2023
Date Signed: 11/08/2023 10:46:45 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/15/2023 and conducted by Evaluator Amy Strother
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20230815150952
FACILITY NAME:WOODSIDE WEST SCHOOLFACILITY NUMBER:
490103579
ADMINISTRATOR:DUMBADSE, DIANAFACILITY TYPE:
850
ADDRESS:2577 GUERNEVILLE ROADTELEPHONE:
(707) 528-6666
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:70CENSUS: 26DATE:
11/08/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Allison FieldsTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Due to lack of supervision, day care child had an unexplained injury

Staff spoke inappropriately to child

Staff did not report the incident to CCLD or the authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Strother made a subsequent complaint investigation inspection for the purpose of delivering the findings, and met with facility representative, Allison Fields (S1). It has been alleged that due to lack of supervision, day care child (C1) had an unexplained injury, specifically when C1 was picked up on 08/02/23 at 4:30pm C1 was observed to have a swollen lip and welt on their forehead. It was also alleged that staff (S3) spoke inappropriately to child C1. Lastly, it has been alleged that staff did not report the injury incident to CCLD or the authorized representative, specifically that C1’s injury that occurred on 08/02/23 was not reported to CCLD or C1’s authorized representative.

During the initial investigation visit to the facility on 08/21/23, LPA Strother met with facility representative, Allison Fields (S1). During the 08/21/23 visit, LPA conducted interviews with three staff (S1 - S3) and received copies of records. During the investigation, LPA interviewed one additional staff member (S4) and obtained additional records on 10/31/23.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 01-CC-20230815150952
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WOODSIDE WEST SCHOOL
FACILITY NUMBER: 490103579
VISIT DATE: 11/08/2023
NARRATIVE
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Based on a record review of sign in/out records dated the week of 07/31/23 – 08/04/23 and corroborated by staff interviews conducted, C1 was signed into care on 08/02/23 at 8:20am and signed out at 4:43pm. Based on a review of record, “Facility Staffing Worksheet” dated 08/02/23 and corroborated by staff interviews conducted, C1 attended the classroom named “Rockets” on 08/02/23 and was in care with staff (S4) from the time C1 arrived until 3:00pm, with the exception of a lunch break from 12-12:30pm, while in care with S3. C1 was then in care with staff S2 and S3 from 3:00pm until 4:30pm, when S2 left the Rockets group of children, and the 11 remaining children, from both the Rockets and TK classrooms were cared for by staff S3. Staff interviews corroborate that staff do face to name checks regularly, including each major transition to include when children go outside after nap at 3:00pm.

Interviews conducted corroborate that C1 did sustain an injury while in care on 08/02/23 and that the injury may have occurred between the time S2 left the Rockets group at 4:30pm and the time C1 was signed out from the facility at 4:43pm. This is based on the report that S2 and S4 did not observe an injury on C1’s face while conducting face-to-name checks prior to leaving the Rockets group. Records indicate that S3 was supervising 11 children in care between 4:30pm and 4:43pm, operating within the ratio requirements. Although C1 did obtain an injury while in care on 08/02/23 that was not observed by staff, it was not due to a lack of supervision, as supervision ratios were maintained. All staff interviewed were able to give examples of what supervision means, to include scanning the room or yard, observing children at play, helping children to problem solve, interacting with children, and conducting face-to-name checks at every major transition throughout the day. Based on an interview conducted, C1 reported to their parent that they sustained the injury when they tripped over their own feet and hit a tire on the yard with their lip and forehead and did not speak to a teacher about it. Based on interviews conducted, although staff S3 did discuss C1 being a quiet child with C1’s parent, while C1 was present at pick up time on 08/02/23, the statements made by S3 did not constitute a violation of C1’s rights. Based on interviews conducted and records reviewed, the injury occurred just moments prior to C1 getting picked up to go home. Since staff was unaware of the injury that occurred, they were not able to report the injury to C1’s authorized representative. C1’s authorized representative discussed the injury in the presence of facility staff, becoming aware of the injury while present at the facility. Staff was not required to report the incident to CCLD, due to, based on interviews conducted and records reviewed C1’s injury did not require medical treatment and C1’s authorized representative did not seek medical attention.

Continue on LIC9099-C
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 01-CC-20230815150952
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: WOODSIDE WEST SCHOOL
FACILITY NUMBER: 490103579
VISIT DATE: 11/08/2023
NARRATIVE
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Based on interviews conducted and records reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, therefore the allegations are unsubstantiated.

There were no Title 22 deficiencies cited during today's inspection.
This report was reviewed and discussed with Facility Representative, Allison Fields. Appeal Rights were provided.

Notice of Site Visit shall be posted for 30 days from today's visit. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3