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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 573615250
Report Date: 05/25/2022
Date Signed: 05/25/2022 12:13:04 PM

Unsubstantiated


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
05/19/2022 and conducted by Evaluator Salene Mayberry
COMPLAINT CONTROL NUMBER: 53-CC-20220519101219
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: 11DATE:
05/25/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Jennifer Mason, Preschool TeacherTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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1. Day care child sustained injury while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Salene Mayberry and Christopher Jackson met with Preschool Teacher Jennifer Mason to open and close the complaint investigation regarding the above allegation.

During the investigation, LPA’s observed the outside play area, conducted interviews and obtained pertinent information and pictures. It was alleged that a child’s personal rights were violated when a child sustained an injury while in care. During interviews it was revealed that although a child was injured while playing outside on a swing, staff was present and quickly provided care and support to the child. The injury did not require medical attention and staff notified the child’s authorized representative promptly of the incident.


Report Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Salene MayberryTELEPHONE: 916-263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
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 2
Control Number 53-CC-20220519101219
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: 05/25/2022
NARRATIVE
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Accordingly, based on LPA’s observations and statements provided the allegation could not be substantiated or dismissed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the finding is UNSUBSTANTIATED.

An exit Interview was conducted with Preschool Teacher Jennifer Mason. Appeal Rights were provided, and LPA posted a Notice of Site Visit 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: 05/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2