493008727-6-21-2019-01-CC-YYAG-BDCM77-20190621092103

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 493008727
Report Date: 06/20/2019
Date Signed: 06/21/2019 09:21:07 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 GOLD RIDGE PRESCHOOL		FACILITY NUMBER:	493008727
ADMINISTRATOR:	PFEIFER, ANDREA		FACILITY TYPE:	850
ADDRESS:	1455 GOLF COURSE DRIVE		TELEPHONE:	(707) 586-1253
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	71	CENSUS: 30	DATE:	06/20/2019
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Jeannine Hernandez		TIME COMPLETED:	12:59 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A case management inspection visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang in response to an incident that occurred at the center on 06/11/19 involving child C1 and child C2. The site supervisor (staff S1) reported that on 06/11/19, staff S2 observed C1 and C2 sitting astraddle on the playground's wood border. S1 reported that S2 observed child C2 place their foot between C1's crotch area. Based off of information provided by S3 and using information gathered from the center's electronic record keeping log, there were 29 children being supervised by 4 teachers on the playground at the time of the incident. The assistant site supervisor (S3) reported that the incident occurred at approximately 11:00am on 06/11/19. It was reported that S1 and S3 were also on site at the time of the incident. During an interview with S2 on 06/20/19 at 10:10am, S2 stated that she was returning to the playground after bringing several children inside the classroom to use the bathroom. S2 reported that when she opened the classroom door leading to the playground, she observed C1 and C2 sitting astraddle on the playground's border and observed C2's foot in C1's crotch area. S2 stated that she immediately told both children to "stop that." S2 stated that C2 stated "[C1] told me to." S2 stated that she spoke with both C1 and C2 and reminded both children that their bodies are private and to keep their hands and feet to themselves. S2 stated that C1 and C2 went on to play without further incidents that day. S2 stated that she reported the incident to S1 and S3. S1 reported that she then notified the 4Cs Program Director and the parents/guardians of C1 and C2. S1 reported that a follow-up parent meeting was scheduled to collaboratively discuss C1's behavior. During today’s inspection, there were 30 children in care being supervised by five staff members. Children were observed to be directly supervised by staff while playing indoors and outdoors. This incident was reported to CCLD as required. Based on information available at this time, there was not a preponderance of evidence to prove that the incident involving C1 and C2 occurred due to a lack of supervision. Continued on LIC 809-C

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang Yang	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2019

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 GOLD RIDGE PRESCHOOL	FACILITY NUMBER: 493008727
	VISIT DATE: 06/20/2019

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A second case management inspection was conducted today due to an incident that occurred on 06/13/19 at approximately 01:40pm. The site supervisor (s1) reported that on 06/13/19, child C3 was on the playground and sitting on "a low bar trying to balance." S1 reported that C3 fell backwards and hit their head. S4 reported that she was standing next to the child at the time of the incident. S4 reported that she observed a cut on the back of C3's head and escorted the child back to the classroom where first aid was administered by center staff. S4 reported that she then contacted the parents/guardians of C3 who arrived at the center and transported the child to the emergency room for treatment. S1 reported that C3 received two staples to the wound on their head. S1 reported that she spoke to the child's parent the following morning and was informed that C3 will return to school the next day.

During today's inspection, LPA inspected the equipment on the play yard and the area of C3's injury. LPA interviewed staff S5 at 10:55am. S5 stated that she observed C3's injury and stated that C3 was sitting on the metal bar and fell backwards and hit their head on the metal frame. The "low bar" appears to be a tubular metal frame of a Go-Kart without wheels. The low bar that C3 was reported to be sitting on is approximately one foot off the pavement. LPA advised the assistant site supervisor that the metal frame posses a potential risk to the children in care. The assistant site supervisor agreed and the metal frame was immediately removed from the play ground area and disposed of in a trash dumpster.

During today’s inspection, there were 30 children in care being supervised by five staff members. Children were observed to be directly supervised by staff while playing indoors and outdoors. This incident was reported to CCLD as required. Based on information available at this time, there was not a preponderance of evidence to prove that the incident involving C3 occurred due to a lack of supervision or a physical plant issue.

Notice of Site Visit shall be posted for 30 days from today's visit.
There were no Title 22 deficiencies cited during today's inspection. This report was reviewed and discussed with assistant site supervisor.

SUPERVISOR'S NAME: Alexis Hollon	TELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang Yang	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2019

LIC809 (FAS) - (06/04)

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