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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570310386
Report Date: 03/07/2022
Date Signed: 03/14/2022 09:51:27 AM


Document Has Been Signed on 03/14/2022 09:51 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833



FACILITY NAME:CATALYST KIDS - CESAR CHAVEZFACILITY NUMBER:
570310386
ADMINISTRATOR:MONROE, MARY ALLISONFACILITY TYPE:
840
ADDRESS:1221 ANDERSON ROADTELEPHONE:
(530) 753-3808
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:124CENSUS: 14DATE:
03/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Savannah RodriguezTIME COMPLETED:
03:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Salene Mayberry and Licensing Program Manager (LPM) Bettina Engelman met with Interim Assistant Site Supervisor Savannah Rodriguez to follow up on the Unusual Incident Report (UIR) submitted to Community Care Licensing on March 4, 2022. During today's visit the facility was toured.

Licensing staff interviewed the Site Supervisor and Staff #1 (S1) who were present during the incident.

Licensing staff learned that on 3/2/22, during the transition to the open field, Child #1 (C1) left the group, remaining in the playground area. Staff #2 (S2) was unaware of C1 being left behind and took the remaining children to the open field. Assistant Site Supervisor and S1, followed the the first group to the open field approximately 10 minutes behind group one with group 2 consisting of 15 children. Upon reaching the field, Site Supervisor and S1 realized the count was off and that a child was missing. S2 then located C1 within 2 minutes approximately 300 feet away from the open field.

A Type A deficiency was cited on the subsequent page (809-D) of this report.

Facility evaluation report was reviewed and discussed with Site Supervisor. Exit interview was conducted. A Notice of Site Visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Salene MayberryTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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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Document Has Been Signed on 03/14/2022 09:51 AM - 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833


FACILITY NAME: CATALYST KIDS - CESAR CHAVEZ
FACILITY NUMBER: 570310386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2022
Section Cited

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No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
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This requirement was not met as evidenced by: Licensing staff learned that Child#1 was left without staff supervision for approximantely 10 minutes on 3/2/2022.
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A live document was created and laminated so staff can track transitions with dry erase.
A Staff Meeting with topices to include visual supervision is scheduled for 3/9/2022. Interim Assistant Site Supvervisor Rodriguez stated that copies of Meeting Agenda and Sign-In Sheets will be submitted to the Department.

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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: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Salene MayberryTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
LIC809 (FAS) - (06/04)
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