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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493009534
Report Date: 12/20/2019
Date Signed: 01/10/2020 08:53:23 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:RAINBOW BRIDGE MONTESSORIFACILITY NUMBER:
493009534
ADMINISTRATOR:KANCHARLA, AISHWARYAFACILITY TYPE:
850
ADDRESS:21 WILLIAM STREETTELEPHONE:
(707) 795-6666
CITY:COTATISTATE: CAZIP CODE:
94931
CAPACITY:0CENSUS: 16DATE:
12/20/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Aishwarya KancharlaTIME COMPLETED:
12:21 PM
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An unannounced case management inspection visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang in response to a self-reported, unusual incident report (UIR) received by the department on 12/06/19. During today's case management visit, LPA met with administrator Aishwarya Kancharla (staff S1) to discuss the incident. The administrator (S1) reported that on 12/03/19 at approximately 02:45pm, child C1 was struck in the head by C2 while both children were playing on the center's outdoor climbing structure. S1 reported that C1 notified teachers S2 and S3 of the injury. S1 reported that C1 was not crying but was upset about the incident. S1 reported that S2 visually inspected C1's head and did not notice any bumps or contusions and subsequently provided an ice pack to C1. S1 reported that after a short while, C1 resumed playing again without holding the ice pack to their head. S1 reported that S4 observed C1 playing and did not believe that the child required any further treatment or medical attention. S1 reported that for the remainder of 12/03/19 and on 12/04/19, teachers at the facility observed C1 to be happy, have normal energy levels, appetite, and sleep during nap time.

The center administrator (S1) reported that on the evening of 12/04/19, C1's teacher, S5, was notified by C1's guardian that C1 was being taken to the emergency room for examination after C1 informed their guardian that C1 was struck in the back of their head by a classmate. S1 reported that on the morning of 12/05/19, S1 called and spoke to C1's guardian regarding C1's hospitalization. S1 stated that C1's guardian informed her that C1 was diagnosed with a concussion after exhibiting signs of motion sickness and vomiting while at the ER. S1 stated that she informed C1's guardian that it is possible the vomiting was the result of a stomach bug, as there was a confirmed case at the center. S1 reported that C1's guardian informed her that C1 was released from the ER that morning.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
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 2
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: RAINBOW BRIDGE MONTESSORI
FACILITY NUMBER: 493009534
VISIT DATE: 12/20/2019
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This incident was reported to Community Care Licensing as required. During today's visit, interviews were conducted and staff were observed to be providing appropriate care and supervision and operating within ratio. Although it was substantiated that C1 sustained an injury while in care, there is not a preponderance of evidence to support that this incident resulted from a lack of supervision or any other Title 22 regulation. This report was read and reviewed with the center administrator. There were no Title 22 deficiencies cited during today's inspection. Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2019
LIC809 (FAS) - (06/04)
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