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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493007570
Report Date: 04/06/2022
Date Signed: 04/06/2022 10:40:12 AM


Document Has Been Signed on 04/06/2022 10:40 AM - 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:BUCKLEY, RACHEL FCCHFACILITY NUMBER:
493007570
ADMINISTRATOR:BUCKLEY, RACHELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 935-6652
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:14CENSUS: 9DATE:
04/06/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rachel Buckley, LicenseeTIME COMPLETED:
10:55 AM
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An unannounced case management visit was made by Licensing Program Analyst (LPA) Kevin O'Connell in response to a self-reported Unusual Incident Report (UIR) that was called in to CCL on 3/23/22 and written report received on 3/29/2022.
During today's case management visit, the LPA met with Licensee, Rachel Buckley (S1) and assistant (S2) to discuss the incident. It was reported that on 03/23/22 at approximately 12:10pm, a child (C1) was running after another on the lawn while playing in the back yard and tripped and fell on his wrist causing a broken bone.

The Licensee reported that the child, along with eleven other children were being supervised by herself and her assistant (S2) at the time of the incident. The Licensee and assistant were both close by when the incident occurred but neither saw it happen. S2 was turned away but a few feet away when she heard C1 crying and called S1 immediately. S1 was in a play structure a few feet away and came immediate to assist. C1 was attended to and parent/ guardian was called who arrived quickly to take C1 to the ER.
LPA spoke to C1's parent on 4/4/22 who stated that C1 was healing well and doing fine. C1 returned to care 3/28/22.

During today's case management visit, the LPA toured the outdoor play area and observed that the area of the incident did not have any obstructions.

This incident was reported to Community Care Licensing and the child's parent/guardian as required. During today's visit, staff were observed to be providing appropriate care and supervision. This report was read and reviewed with the Licensee, Rachel Buckley. There were no Title 22 deficiencies cited during today's inspection. Notice of Site Visit is to be posted for 30 days from today.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Kevin O'ConnellTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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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