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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110022
Report Date: 01/25/2024
Date Signed: 01/25/2024 03:58:23 PM

Document Has Been Signed on 01/25/2024 03:58 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:A SPECIAL PLACEFACILITY NUMBER:
490110022
ADMINISTRATOR:BLANCA HERNANDEZFACILITY TYPE:
850
ADDRESS:1128 EDWARDS AVENUETELEPHONE:
(707) 523-2337
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 9DATE:
01/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Blanca HernandezTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Amy Strother made an unannounced Case Management visit to the facility and met with facility representative, Blanca Hernandez (D1). On 01/22/24 the Department received an Unusual Incident Report from D1, reporting that on 01/19/24 during outside play, around 11:50am, the children lined up to go inside for lunch. The report states that teacher, Staff 1 (S1) was at the front of the line of children, with D1 at the back of the line holding hands with two children Child 1 (C1) and Child 2 (C2), when C1 ran away from the line and back out to the play ground area. The report states that D1, along with C2 left the line to go get C1, asking C1 to come inside for lunch. D1 reports that she, along with C1 and C2 entered the building and Staff 2 (S2), who had been inside setting the lunch table, closed the door behind them from inside the building. S2 reportedly heard a knock at the door, just after closing it, opened the door to see Child 3 (C3) standing outside the door. The report states that C3 must have hide behind the door while D1 was getting C1 to return to the line and was only outside the door for just a few seconds after S2 closed the door, before being let in by S2. The incident report stated that the teachers are going to count the children at any transition, all teachers are going outside with the children and all the teachers are coming in with the children for lunch.

During today's visit LPA asked D1 for a detailed explanation on how transitions from inside to outside and outside to inside will be conducted. D1 stated that she will have a roster of the children printed each day on a clip board. One teacher will be ready to receive the children inside or outside, one teacher will stand at the door putting a check mark next to the child's name as they enter or exit and a third teacher will check that no child is left inside or outside and then close the door and do a head count, writing the number on a dry erase board.

There were no Title 22 deficiencies cited during today's inspection.

This report was reviewed and discussed with Facility Representative, Blanca Hernandez. 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.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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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