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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009176
Report Date: 01/31/2022
Date Signed: 02/15/2022 10:11:39 AM


Document Has Been Signed on 02/15/2022 10:11 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/15/2022 09:38 AM

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

NARRATIVE
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***This statement is the only amendment of the original document. Read Receipt on file.***

The Administrator listed above, Joseph Le Blanc, has not been employed by the facility since May 2021 and did not work at the facility during the time of the incident listed below.

A Case Management inspection was conducted at the facility by Licensing Program Analyst (LPA) Amy Strother in response to an Unusual Incident Report reported and filed by co-Licensee Jenny Kenyon (L1) about a 01/03/22 incident where a child (C1) eloped from the facility, leaving the enclosed campus without supervision and without staff noticing their elopement. C1 was discovered on the sidewalk by an unknown adult in the neighborhood. L1 reported the incident on the date of occurrence, 01/03/2022.

LPA interviewed L1 about the incident during a phone conversation on 01/03/22. During today's visit, LPA obtained facility documents and interviewed one staff, Staff 1, who was present on 01/03/22, regarding the incident. The facility was closed at the time of this inspection, due to an afternoon staff development day, but L1 agreed to allow the inspection to occur.

According to facility documents reviewed, and interviews conducted, the following is a summary of what occurred on 01/03/22: There were 14 children present with 2 teachers, S1, Staff 2 (S2) and Licensee (L1). S1 took a 10-minute break from approximately 11:02am to 11:12am, during which time C1 was consoled multiple times because they were reportedly missing S1. At 11:12am S1, S2, L1 and the children were outside on the playground when it started to rain. When the rain started, a transition to opening one classroom began, to allow for indoor/outdoor play options. At 11:16am L1 left the classroom to work in the office, leaving S1 outside supervising children and S2 inside supervising children. Around this time, 11:16am, a car drove by the outdoor playground, located on Humboldt Street, the driver called out, that there was a child on the sidewalk wearing a red coat and blue shoes at Humboldt St and Silva Ave. At this time S1 identified that C1 was missing. At 11:18am L1 ran through the building to Humboldt Street. Approximately one block down Humboldt Street, L1 observed C1 with a police officer, PG&E employee, and neighbors. At 11:20am L1 brought C1 back to the facility with the police officer. Once safely inside the facility, L1 notified C1’s parents and Community Care Licensing of the incident. L1 states that is her belief that C1 eloped through the gate located at the front of the facility, accessible from the playground.

Continue on LIC809-C

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: HUMBOLDT COMMUNITY PRESCHOOL
FACILITY NUMBER: 493009176
VISIT DATE: 01/31/2022
NARRATIVE
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L1 stated that the latch on the gate is at child height, and although it has a string securing the gate, it was determined not to be short enough to prevent the gate from opening wide enough for a child to fit through. Additionally, the gate is spring loaded and closes after being pushed through. L1 stated that a breech in supervision allowed C1 to elope from the facility.

L1 notified LPA Strother on 01/03/22 that the facility will be closed through 01/09/22 while Licensees institute changes to prevent elopements in the future. L1 provided LPA with a copy of a letter sent to all parents to make them aware of the unusual incident, the plan to close the facility for the remainder of the week and the intention to take time to fully evaluate the safety of the facility to prevent future elopements.

During today's inspection L1 stated that the gate on the playground has been replaced and is now higher than it was previously, and has two bells hanging on springs making it audible when opened and closed. L1 has conducted at least two staff training's regarding supervision on 02/03/22 and 03/10/22 using the Early Childhood National Centers, Active Supervision at-a-glance and Active Supervision Toolkit as training materials.

Based on documents reviewed and interviews conducted, it is estimated that C1 was without supervision and outside the enclosed campus sometime between 10:53am and 11:20am. Based on available information, it has been determined that staff did not provide supervision to C1 during the incident on 01/03/2022. The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. An immediate $500 civil penalty has been assessed for the absence of supervision violation. Appeal Rights were provided.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the licensee, Jenny Kenyon.

LPA Strother informed licensee Jenny Kenyon that this report dated 01/31/22 document(s) one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Strother informed the licensee Jenny Kenyon to provide a copy of this licensing report dated 01/31/2022 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2022 05:14 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: HUMBOLDT COMMUNITY PRESCHOOL

FACILITY NUMBER: 493009176

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2022
Section Cited

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Levy of civil penalty in addition to suspension, temporary suspension, or revocation; amounts; regulations setting forth appeal procedures for deficiencies (c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation, for any of the following serious violations: (3) Absence of supervision, including, but not limited to, a child left unattended, and supervision of a child by a person under 18 years of age.
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This requirement has not been met as evidenced by: On 01/03/22, C1 left the facility unattended, resulting in an absence of supervision, which poses an immediate Health and Safety risk to children in care.
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L1 stated that a staff training on the topic of active supervision was conducted on 02/03/22 and 03/10/22. L1 will submit a sign in sheet of staff in attendance of trainings, to include S1 and S2 to LPA Strother's email amy.strother@dss.ca.gov by 02/01/22.

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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: Amy StrotherTELEPHONE: (707) 588-5077
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022
LIC809 (FAS) - (06/04)
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