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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493004931
Report Date: 05/11/2023
Date Signed: 05/11/2023 04:15:33 PM


Document Has Been Signed on 05/11/2023 04:15 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:4CS OLD ELM CHILD DEVELOPMENT CENTERFACILITY NUMBER:
493004931
ADMINISTRATOR:FANNY SALASFACILITY TYPE:
850
ADDRESS:305 W. PAYRAN STREET, STE #CTELEPHONE:
(707) 782-0408
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:42CENSUS: 28DATE:
05/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Fanny SalasTIME COMPLETED:
02:31 PM
NARRATIVE
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An unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang in response to a self-reported, lack of supervision incident involving child C1 and staff S1 that occurred on 04/17/23. During today’s visit, the LPA met with the Site Supervisor, Fanny Salas to discuss the incident.

It was reported by Site Supervisor Salas that on 04/17/23, child C1 was left on the center’s main playground, which is fully fenced, without staff supervision for between three-to-five minutes. The Site Supervisor reported that staff S1 was on the playground with five children at approximately 03:05pm. The Site Supervisor reported that S1 transitioned indoors for snack time with the four other children, leaving C1 outside. The Site Supervisor reported that a child in C1’s classroom reported to staff S2 that C1 was still outside. The Site Supervisor reported that staff S3 then went outside to retrieve the child. The Site Supervisor reported that while outside, C1 soiled themselves and was changed by S3 when brought back inside. The Site Supervisor reported that S3 then escorted C1 back to their class. The Site Supervisor reported that staff are required to perform “name to face” checks at every transition. The Site Supervisor reported that a name to face check was not performed prior to this incident.

This self-reported incident was reported to CCLD as required per regulations. The Site Supervisor reported that this incident was also reported to the 4C’s Director of Preschool Program, Jenny Copeland as well as the child’s authorized representative. The Site Supervisor reported that a follow-up all staff meeting was held on 04/19/23 at the center to discuss the incident. The Site Supervisor reported that additional training was provided to staff regarding the topics of care and supervision and indoor to outdoor and outdoor to indoor transitions. During today’s case management visit, no children were observed to be left without supervision.

Based on available information, it has been determined that preschool staff S1 did not provide adequate supervision to child C1 during the incident on 04/17/2023. The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. This report was read and reviewed with the Site Supervisor, Fanny Salas. Notice of site visit shall be posted for 30 days. Appeal rights provided

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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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Document Has Been Signed on 05/11/2023 04:15 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: 4CS OLD ELM CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 493004931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited

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Care and Supervision. No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation. This requirement was not met as evidenced by: based on the Site Supervisor's admission on 05/11/23 and the unusual incident report (UIR) submitted to CCLD on 04/19/23 that on 04/17/23 at approximately 03:05pm, child C1 was left without supervision of a teacher for approximately three-to-five minutes while on the preschool playground before being reunited with their class. The Site Supervisor reported that C1's class transitioned indoors while C1 remained outdoors on the fully fenced play yard.


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This deficiency was cleared during today's case management visit. The Site Supervisor provided proof to the LPA of the all staff meeting held on 04/19/23 to discuss the incident and provide training to staff on care and supervision and indoor to outdoor and outdoor to indoor transitions. The Site Supervisor reported that she also reviewed with staff the care and supervision video produced by Community Care Licensing.
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This presents a potential threat to the health and safety of children 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: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
LIC809 (FAS) - (06/04)
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