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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490107083
Report Date: 03/27/2024
Date Signed: 03/27/2024 05:07:34 PM


Document Has Been Signed on 03/27/2024 05:07 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:J.X. WILSON EXTENDED CHILD CAREFACILITY NUMBER:
490107083
ADMINISTRATOR:HOLLY MAYFACILITY TYPE:
840
ADDRESS:246 BRITTAIN LANETELEPHONE:
(707) 575-6988
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:96CENSUS: 19DATE:
03/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Holly MayTIME COMPLETED:
05:20 PM
NARRATIVE
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A case management visit to the facility was made today by Licensing Program Analyst (LPA) Amy Strother in response to a child elopement incident at the facility on 03/19/24. The incident was reported by phone to Community Care Licensing (CCL) on 03/20/24, followed by a written Unusual Incident Report (UIR) received by CCL on 03/21/24, in compliance with the reporting requirements. LPA interviewed the Executive Director of Extended Child Care (D3) on 03/25/24 and received additional records from D3 on 03/26/24, including written statements from staff regarding the incident. During today’s visit, LPA Strother met with Center Director, Holly May (D2).

This incident occurred during the week of Spring Break, 03/18/24-03/22/24 . At the time of the incident students and staff from two additional Extended Child Care locations were located at J.X. Wilson Extended Child Care, including Center Director (D1). D1 was the Center Director present at J.X. Wilson during during the 03/19/24 incident. Based on the UIR report, on 03/19/24 at approximately 10:50am, a 12 year old child (C1) was discovered to be missing, 5 minutes following the group returning to the classroom from outside free choice time. Based on record review, there were a total of 32 children, supervised by four facility staff (D1 and S1-S3) at the time of the incident. The facility was operating within the licensed capacity and ratio requirements. The UIR states that the outdoor play time occurred from approximately 9:45am to 10:45am. Based on record review, S1 reported last seeing C1 on the playground at approximately 10:30am. The UIR states that head counts/roll call was not taken before heading back into the classroom and no staff witnessed C1 leaving the facility. The UIR states that D1 called the Santa Rosa Police Department (SRPD) at 12:25pm and made several attempts to contact C1’s mother by phone, after looking all around the campus for C1 and not locating them. Multiple staff stated that C1 does not have a history of eloping or attempting to elope. Based on record review, C1 asked staff person (S4) about potential consequences if a student were to leave campus the day prior, on 03/18/24. S4 did not report the conversation to D1 or any other staff. The UIR states that C1’s mother called the facility at approximately 12:50pm, stating that C1 had been located at a friend’s house and was safe. D1 confirmed with SRPD that C1 was found and safe.

Continue on LIC809-C

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: J.X. WILSON EXTENDED CHILD CARE
FACILITY NUMBER: 490107083
VISIT DATE: 03/27/2024
NARRATIVE
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LPA requested and obtained a dispatch summary of the incident from SRPD on 03/25/24. A review of the report from SRPD documents that C1 was located at 1:02pm on 03/19/24, 2.3 miles from J.X. Wilson Extended Child Care, a distance that takes 52 minutes to walk, according to Google Maps.

Based on interview and record review, it has been determined that staff did not provide supervision to C1 during the incident on 03/19/2024. The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. An immediate $500 civil penalty has been assessed for the absence of supervision violation. Appeal Rights were provided.

During today's inspection D2 and 2 staff (S2 & S5) were supervising a total of 19 students, operating within the licensed capacity and ratio requirements. Staff were observed communicating by walkie talkie about taking groups of children on bathroom breaks, informing one another the number of children who were going to the bathroom. Staff were also observed tracking numbers of students by way of a "Tracking Sheet". D2 explained that the names that are highlighted are present students. LPA observed D2 crossing out the child's name as they were picked up and then adjusting the "# count" on the right side of the tracking sheet to reflect the new total number of children present.

LPA Strother informed facility representative, Holly May that this report dated 03/27/24 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Strother informed facility representative Holly May to provide a copy of this licensing report dated 03/27/2024 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with Center Director, Holly May.

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

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 03/27/2024 05:07 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: J.X. WILSON EXTENDED CHILD CARE
FACILITY NUMBER: 490107083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2024
Section Cited
HSC
1596.99(c)(3)

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Levy of civil penalty in addition to suspension, temporary suspension, or revocation; amounts; regulations setting forth appeal procedures for deficiencies (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation, for any of the following serious violations: (3) Absence of supervision, including, but not limited to, a child left unattended, and supervision of a child by a person under 18 years of age.
This requirement has not been met as evidenced by:
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On 03/26/24 LPA received from D3 a memo outlining the immediate response taken by D3 and Director of Talent & Quality Initiatives (D4) and an outline of corrective actions, including a statement that D4 will be reviewing the following with ECC center staff beginning on 03/25/24: Supervision, Tracking Students, General Communication and Chain of Command, and Missing Child Procedures.
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On 03/19/24, C1 left the facility unattended, resulting in an absence of supervision for at least 2 hours and 17 minutes, from 10:45am the end of outdoor play, when C1 walked 2.3 miles from campus to a friend’s house and was located by SRPD at 1:02pm, which poses an immediate Health and Safety risk to children in care.
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On 03/27/24 D3 emailed all ECC Center Directors, CCing LPA Strother a step by step process for tracking students to be implemented effective immediately. The email states that a Center Director’s meeting will be held on 04/04/24 to finalize the tracking procedures. D3 will submit the finalized tracking procedures to LPA once finalized.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
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