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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008727
Report Date: 02/14/2024
Date Signed: 02/14/2024 01:52:58 PM


Document Has Been Signed on 02/14/2024 01:52 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 GOLD RIDGE PRESCHOOLFACILITY NUMBER:
493008727
ADMINISTRATOR:COPELAND, JENNYFACILITY TYPE:
850
ADDRESS:1455 GOLF COURSE DRIVETELEPHONE:
(707) 586-1253
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:71CENSUS: 25DATE:
02/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Claudia Avalos, Site SupervisorTIME COMPLETED:
01:29 PM
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An unannounced case management visit was made by Licensing Program Analyst (LPA) Y. Yang to follow up on an Unusual Incident Report (UIR) submitted by the facility on 01/29/24. The LPA met with the site supervisor, Claudia Avalos today to discuss the incident. The facility reported that on 01/24/24, child C1 was left without staff supervision while at the facility. During today's visit, the LPA conducted staff interviews and made observations inside the classroom.

Due to insufficient information available at this time, a follow up visit will be conducted at a later date. This report was read and reviewed with the site supervisor, Claudia Avalos. There were no Title 22 deficiencies cited during this visit. The Notice of Site Visit shall be posted for 30 days.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024
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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