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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573600620
Report Date: 10/28/2021
Date Signed: 10/28/2021 03:14:16 PM

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 - GIBSONFACILITY NUMBER:
573600620
ADMINISTRATOR:OSTERHOUDT, ASHLEYFACILITY TYPE:
840
ADDRESS:312 GIBSON ROADTELEPHONE:
(530) 666-4822
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:74CENSUS: 22DATE:
10/28/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Assistant Site Supervisor, Ben PascaleTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Chayntel Hunter met with Assistant Site Supervisor, Ben Pascale to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 10/11/2021. During today's visit the facility was toured. Present were 22 school age children in care and 3 staff.

LPA interviewed the Assistant Site Supervisor and staff who were present during the incident. Interviews conducted revealed that a child (C1) left the facility playground and was retrieved by a parent, at the center's entrance. The child was out of staff's line of sight for approximately 2- 5 minutes. Based on the information obtained LPA determined C1 was left unattended.

The facility reported the UIR to Community Care Licensing and submitted a written UIR, describing the specifics of the incident. The Assistant Site Supervisor stated they have moved to a different playground on the school grounds to obtain better visual supervision of children. Assistant Site Supervisor has held a staff meeting to discuss Title 22 regulations regarding supervision and zoning.

Facility evaluation report was reviewed and discussed with Site Supervisor. The following Title 22 Deficiency is being cited on the subsequent 809-D page. Upon receipt of Type A citations, licensee shall post and provide copies of the LIC 809-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 809-D in each child's file. LPA reviewed and discussed this report with the Assistant Site Supervisor. Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.
SUPERVISOR'S NAME: Justin L DentonTELEPHONE: (916) -92-0269
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: CATALYST KIDS - GIBSON
FACILITY NUMBER: 573600620
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/29/2021
Section Cited

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Responsibility for Providing Care and Supervision. No child(ren) shall be left without the supervision of a teacher at any time... Supervision shall include visual observation. This requirement was not met as evidenced by: LPA Hunter received a UIR stating that there had been an incident
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where C1 had left the facility playground and walked towards the center's entrance, where the child was found by a parent. Based on the information obtained LPA determined C1 was left unattended for approximately 2-5 minutes. This poses an immediate health and safety risk to children in care.
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Civil Penalty assessed.

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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: Justin L DentonTELEPHONE: (916) -92-0269
LICENSING EVALUATOR NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2021
LIC809 (FAS) - (06/04)
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