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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 573615250
Report Date: 04/28/2022
Date Signed: 04/28/2022 12:46:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/18/2022 and conducted by Evaluator Salene Mayberry
PUBLIC
COMPLAINT CONTROL NUMBER: 53-CC-20220318111334
FACILITY NAME:DAVIS WALDORF SCHOOLFACILITY NUMBER:
573615250
ADMINISTRATOR:BREWER, KELLYFACILITY TYPE:
850
ADDRESS:3100 SYCAMORE LANETELEPHONE:
(530) 753-1651
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY:75CENSUS: 12DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Jennifer Slater, DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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1. Lack of Supervision: Daycare child sustained an injury while in care
2. Reporting Requirements: Staff did not properly report an incident involving a daycare child
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Salene Mayberry and Licensing Program Manager (LPM) Bettina Engelman met with Director, Jennifer Slater to deliver findings of the complaint investigation regarding the above allegations.

During the investigation, LPA conducted interviews, and obtained information pertinent to the allegations. It was alleged that a day care child sustained an injury while in care due to a lack of supervision. During interviews it was revealed a child was using a stone mortar and pestle and dropped it, sustaining an injury to their foot. Interviews with staff also revealed the child was left alone in the classroom with a parent volunteer while staff were outside with the remaining group of children.

Report Conttinued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Salene MayberryTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 53-CC-20220318111334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: DAVIS WALDORF SCHOOL
FACILITY NUMBER: 573615250
VISIT DATE: 04/28/2022
NARRATIVE
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It was also alleged that “staff did not properly report an incident involving a day care child”. LPA’s investigation revealed that no report was made to the Department regarding this incident, and that staff knew or should have been aware that medical attention was received for the injury sustained. Director Slater indicated she was not made aware of the incident by staff.

Based on the information obtained during the investigation the evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. The following Title 22 Deficiencies are being cited on the subsequent 9099-D page. Upon receipt of Type A citations, Director Slater shall provide copies of the LIC 9099-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Director Slater must also keep the signed LIC9224, acknowledging receipt of LIC9099-D in each child's file.

Appeal Rights were provided, and LPA posted a Notice of Site Visit with Type A Deficiency Page, which must remain posted for 30 days.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Salene MayberryTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 53-CC-20220318111334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: DAVIS WALDORF SCHOOL
FACILITY NUMBER: 573615250
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited
CCR
101229(a)(1)
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Providing Care and Supervision. 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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Director stated she will have facility staff do superviosion training and sign an acknwledgement of understanding. She will also have staff watch a video about supervision. Staff will also receive training on the role of parent volunteers.
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This requirement was not met as evidenced by: LPA learned that a child was left with a volunteer without the visual supervision of a teacher and sustained an injury that required medical attention on 12/8/21. This is an immediate risk to health and safety of children in care.
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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: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 53-CC-20220318111334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: DAVIS WALDORF SCHOOL
FACILITY NUMBER: 573615250
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2022
Section Cited
CCR
101212(d)(1)(B)
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Reporting Requirements. Upon the occurrence, during the operation of the child care center. . .a written report. . . shall be made to the Department. . .of any injury to a child that requires medical attention. This requirement was not met as evidenced by:
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Director stated that facility staff will go over incident reports and how licensing is involved so they can better understand the whole process. Director will include this in a training to be completed within two weeks from today.
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No report was made to the Department after a child sustained an injury that required medical attention. This poses a potential risk to the health and safty to children in care.
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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: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4