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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493005826
Report Date: 12/18/2019
Date Signed: 12/23/2019 09:40:23 AM

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:4CS PAULIN CREEK CDC - PRESCHOOLFACILITY NUMBER:
493005826
ADMINISTRATOR:HINCHER, NATALIEFACILITY TYPE:
850
ADDRESS:2614 PAULIN DRIVETELEPHONE:
(707) 565-3420
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:45CENSUS: 34DATE:
12/18/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Natalie Hincher, Site SupervisorTIME COMPLETED:
01:00 PM
NARRATIVE
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A Case Management inspection was conducted at the facility by Licensing Program Analyst (LPA) N. Cunningham in response to an Unusual Incident Report (UIR) received on 11/18/19 involving a lack of supervision. The site supervisor reported that on 11/14/19 at approximately 11:45am, child 1 (C1) and child 2 (C2) separated from the group, went into the small classroom and played with cars. Three staff (Staff 1 -3) supervising children did not notice C1 and C2 separate from the group. While inside, C1 took off their tank top and put it on inside out. All staff reported, C1 complained of wood chips in their clothes and believe C1 may have removed their tank top to find and discard wood chips. Staff also stated 11/14/19 was pajama day and C1 was wearing a tank top and shorts because earlier they removed their footed pajamas. The site supervisor estimates C1 was unsupervised for approximately 5 minutes and C2 was unsupervised for 3 minutes. The site supervisor reported C1 and C2's parent was informed of the incident.

The site supervisor reported that they now conduct a head count when children transition from one location to another and one teacher is now positioned at the doorway at all times when children are outside. The site supervisor also stated a chime was ordered and will be installed this month. During today’s inspection, interviewed three staff (S1-S3), reviewed c1 and c2 file, and obtained a facility roster.

Based on available information, it has been determined that preschool staff did not provide supervision to C1 and C2 during the incident at 11:45am on 11/14/2019. 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. Notice of site visit must be posted for 30 days. Appeal rights provided.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Nicolette CunninghamTELEPHONE: (707) 588-5056
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2019
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: 4CS PAULIN CREEK CDC - PRESCHOOL
FACILITY NUMBER: 493005826
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2019
Section Cited

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(a) The licensee shall provide care and supervision as necessary to meet the children's needs. (1) 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.
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This requirement was not meet by evidence: On 11/14/19, two children were without visual supervision for approximately 3-5 minutes. The site supervisor reported the incident. Interviews conducted on 12/18/19 corroborate the information in the Unusual Incident Report.
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areas that there are no teachers and asking teachers when they need to use the restroom. A chime will be placed on the outside door and the door between the bathroom and small classroom to alarm teachers when the door is opened.

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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: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Nicolette CunninghamTELEPHONE: (707) 588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2019
LIC809 (FAS) - (06/04)
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