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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173003097
Report Date: 10/18/2024
Date Signed: 10/18/2024 01:27:10 PM

Document Has Been Signed on 10/18/2024 01:27 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:POMO EARLY CONNECTIONFACILITY NUMBER:
173003097
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, TERESAFACILITY TYPE:
850
ADDRESS:3350 ACACIA STREETTELEPHONE:
(707) 994-1960
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 30TOTAL ENROLLED CHILDREN: 30CENSUS: 5DATE:
10/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Teresa HernandezTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On 09/26/2024, Licensing Program Analysts (LPA), Sebastian Phouthaovong made an unannounced Case Management visit in response to a self-reported Unusual Incident Report (UIR). UIR was notified to Community Care Licensing on 09/05/2024. The incident was regarding a child running out of the facility's playground to the upper playground by the main gate. LPA met with Site Supervisor, Teresa Herandez and spoke with her the purpose of today's visit.

During today's inspection, LPA toured the facility inside and out and observed five children being supervised by three staff members. LPA conducted interviews with the Site Supervisor and two staff members. Site Supervisor stated the incident was discussed by staff and plan was created to ensure children are proper supervised when at the playground. In addition, the facility added gates to the facility's playground.

Site Supervisor reviewed the Reporting Requirements to notify the Department by telephone or fax within the Department's next working day and during its normal business hours. Then to submit a a written report Unusual Incident Report (UIR) within seven days. Regulation 101212 Reporting Requirements was provided.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Site Supervisor, Teresa Herandez.

There were no Title 22 deficiencies cited during today's inspection.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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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