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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 034500943
Report Date: 12/11/2023
Date Signed: 12/11/2023 11:30:22 AM

Document Has Been Signed on 12/11/2023 11:30 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GOLD STAR PRESCHOOLFACILITY NUMBER:
034500943
ADMINISTRATOR:LOFFSWOLD, MICHELLEFACILITY TYPE:
850
ADDRESS:190 FOGARTY RDTELEPHONE:
(209) 256-8059
CITY:SUTTER CREEKSTATE: CAZIP CODE:
95685
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: DATE:
12/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Director, MichelleTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Santiago and (LPM) Chayntel Hunter met with Director, Michelle, Michelle to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 11/28/2023. During today's visit the facility was toured. Present were 14 children in care and 2 staff.

LPA interviewed the Director, who was present during the incident. LPAs reviewed and discussed this report with the Director. Through interviews conducted, LPAs learned that at the time of the incident a child (C1) had bitten a pill found in the facility around lunch time. After C1 bit the pill, C1 took the pill to teacher, staff (S1) who showed the Director. LPAs learned the parent were not immediately notified.
Director stated they are going to add a new protocol with staff, due to the incident that occurred. LPAs reviewed the new protocol which includes immediately calling poison control, 911, and the parents.

The facility reported the UIR to Community Care Licensing within 24hrs. A written UIR was submitted within 7 days, describing the specifics of the incident.

Facility evaluation report was reviewed and discussed with Director. Exit interview was conducted. Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.

The following Title 22 Deficiency is being cited on the subsequent 809-D page.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Elizabeth Santiago
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2023
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 12/11/2023 11:30 AM - It Cannot Be Edited


Created By: Elizabeth Santiago On 12/11/2023 at 10:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GOLD STAR PRESCHOOL
FACILITY NUMBER: 034500943

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2024
Section Cited
CCR
101226(b)

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101226 Health-Related Services
(b) The licensee shall make prompt arrangements for obtaining medical treatment for any child if necessary.
This rrequirement was not met as evidenced by:
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Director has implemented a poison protocol which outlines that the facility wil Immediately wash out the child’s mouth, call the facility’s local poison control, call child’s parents, and call 911, if necessary. LPA and LPM will hold an informal meeting and reviewed the protocal with
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Through interviews and review of records it was determined that C1 bit into a medicine capsule, and the facility did not seek medical attention, nor was the parent promptly notified of the incident. Which poses a potential health, safety or personal rights risk to persons in care.
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 staff signatures during today's visit. LPA will clear the deficiency today.


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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:Chayntel Hunter
LICENSING EVALUATOR NAME:Elizabeth Santiago
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023


LIC809 (FAS) - (06/04)
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