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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110022
Report Date: 03/04/2020
Date Signed: 03/04/2020 04:25:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:A SPECIAL PLACEFACILITY NUMBER:
490110022
ADMINISTRATOR:WENDY ADAMSFACILITY TYPE:
850
ADDRESS:1128 EDWARDS AVENUETELEPHONE:
(707) 523-2337
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:30CENSUS: 26DATE:
03/04/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Laura VioghtTIME COMPLETED:
04:40 PM
NARRATIVE
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At 1:22pm on 03/04/20, Licensing Program Analyst (LPA), Amy Strother, conducted a case management inspection in regard to an incident report submitted to CCL on 02/12/20. LPA met with site supervisor, Laura Vioght.

The incident report dated 02/12/20 reported that Child 1 (C1) sustained an injury while participating in an art activity while in care that required medical attention. LPA toured the building and inspected the location of the incident, the picnic table/art area. LPA interviewed Staff 1 (S1) regarding this incident who stated that she did not observe the incident occur although she was on the playground at the time of the incident. S1 stated that there was one other staff member, Staff 2 (S2) on the playground in close proximity to C1 when the incident occured, but that S2 did not observe the incident. During the interview with S1, S1 stated that S2 was responsible for supervising the picnic table area and another portion of the play yard. LPA observed that for a staff to supervise areas of the play yard other than the picnic table area, the staff would need to turn their back to the picnic tables, and therefore can not provide adequate care and supervision to the children in the picnic table area. Although the facility properly reported the incident, provided immediate care to the injured child and notified the child's authorized representative in a timely manner, based on the interview conducted with S1, the children at the picnic table, which included the child that sustained an injury on 02/12/20 were not visually supervised at all times.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D.

An exit interview was conducted and Plans of corrections were reviewed and developed with the Site Supervisor in person and the Director via telephone. Appeal Rights were provided and discussed with the Site Supervisor whose signature on this form confirm receipt of these documents.

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: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: A SPECIAL PLACE
FACILITY NUMBER: 490110022
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/04/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2020
Section Cited

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Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary to meet the children's needs.(1)No child(ren) shall be...without the supervision...at any time, except as specified... Supervision shall include visual observation.
This requirement is not met as evidenced by:
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Based on observation and interview the licensee did not ensure that all areas of the yard could be supervised with the number of staff on the yard at any one time, leaving parts of the yard unsupervised,which poses a potential Health, Safety or Personal Rights risk to the children in care.
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when only one staff with 8 children is present on the playground, reducing the area to supervise. Staff will use cell phones to call/text staff inside to assist with children that need to use the bathroom or alternatively line up the children and all come inside to use the bathroom together by 03/25/20.

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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: 03/04/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2020
LIC809 (FAS) - (06/04)
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