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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490111657
Report Date: 10/05/2023
Date Signed: 10/05/2023 04:18:57 PM


Document Has Been Signed on 10/05/2023 04:18 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:BRUSH CREEK MONTESSORI SCHOOLFACILITY NUMBER:
490111657
ADMINISTRATOR:SUSAN MORRELLFACILITY TYPE:
850
ADDRESS:1569 BRUSH CREEK ROADTELEPHONE:
(707) 539-7980
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:78CENSUS: 57DATE:
10/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Nicole SaladygaTIME COMPLETED:
04:28 PM
NARRATIVE
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An unannounced Case Management visit was made to the facility by Licensing Program Analyst (LPA) Amy Strother to address an incident that was brought to the attention of the Department by way of a complaint allegation: Daycare child was left unattended outside of the facility classroom, compliant report 01-CC-20230713085830, dated 07/13/23. LPA met with the Director of Operations, Nicole Saladyga (S1). The compliant report specifically stated that April 24, 2023, Child 1 (C1) escaped from the Saplings classroom and was left unattended outside of the facility classroom. The reporting party stated that the Center Director (D1) was aware of the incident but did not report it to Community Care Licensing (CCL) as required. LPA interview with D1 indicates that D1 was aware of the incident and had a gate installed on the ramp outside of the classroom after learning about the incident. D1 did not notify CCL of the incident with a phone call or submit an Unusual Incident Report (UIR) as required.

The following deficiency is being cited (see LIC 809D). Appeal Rights were provided.

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 the Director of Operations, Nicole Saladyga (S1).

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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 2


Document Has Been Signed on 10/05/2023 04:18 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: BRUSH CREEK MONTESSORI SCHOOL
FACILITY NUMBER: 490111657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2023
Section Cited
CCR
101212(d)(1)(C)

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101212 ...during the operation of the child care center if any of the events specified in (d)(1) below, a report shall be made to the Department by… next working day... In addition, a written report…shall be submitted to the Department within seven days...(1)Events reported shall include the following: (C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement was not met as evidenced by:
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Director of Operations and Center Director will watch the Child Care Center Reporting Requirements Video on CCLD’s website: https://ccld.childcarevideos.org/child-care-center-operators/child-care-reporting-requirements/ and then send to LPA Strother the signatures declaring that the video has been viewed and a written procedure for how reporting will be handled in the future.
amy.strother@dss.ca.gov
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Based on interview D1 was aware of an incident where Child 1 (C1) left the Saplings classroom unsupervised, but did not report it to the Department and did not submit a written incident report timely as required. This poses a potential health, safety or personal rights risk to persons in care.
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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: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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