214005479-5-12-2022-05-CC-CINO-CEKQGW-20220519121012

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 214005479
Report Date: 05/11/2022
Date Signed: 05/12/2022 12:19:56 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2022 and conducted by Evaluator Haydee R Caliboso

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20220506172359

FACILITY NAME:	NORTH BAY CHILDREN'S SCHOOL		FACILITY NUMBER:	214005479
ADMINISTRATOR:	GILMORE, SUSAN		FACILITY TYPE:	850
ADDRESS:	940 C STREET ANNEX		TELEPHONE:	(415) 883-6222
CITY:	NOVATO	STATE: CA	ZIP CODE:	94949
CAPACITY:	45	CENSUS: 27	DATE:	05/11/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Nicole Porter		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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9

Day-care child fell resulting in injury.

INVESTIGATION FINDINGS:

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On 5/11/22 at 9:30am., Licensing Program Analyst (LPA) Haydee Caliboso arrived at the facility to conduct a 10-day complaint inspection in response to the above allegation(s). LPA met with Director, Nicole Porter. Present during the inspection were 27 preschool-aged children, 8 staff, and Director.

Based on LPA's gathered information through observations and interviews with staff, the agency has investigated the complaint allegation(s) above. Child fell, and sustained injury while in care. There’s no evidence to proof that the injury was due to lack of supervision. Although, the lack of supervision may have happened or maybe valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur. Therefore the allegation(s) is closed and found to be UNSUBSTANTIATED.

No deficiencies were cited against the facility under CCR,Title 22, Div. 12, Ch.1
An exit interview was conducted. A Notice of Site Visit was posted during this inspection.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2022 and conducted by Evaluator Haydee R Caliboso

PUBLIC

COMPLAINT CONTROL NUMBER: 05-CC-20220506172359

FACILITY NAME:	NORTH BAY CHILDREN'S SCHOOL		FACILITY NUMBER:	214005479
ADMINISTRATOR:	GILMORE, SUSAN		FACILITY TYPE:	850
ADDRESS:	940 C STREET ANNEX		TELEPHONE:	(415) 883-6222
CITY:	NOVATO	STATE: CA	ZIP CODE:	94949
CAPACITY:	45	CENSUS: 27	DATE:	05/11/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Nicole Porter		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
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5
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7
8
9

Staff did not notify parent of an incident.

INVESTIGATION FINDINGS:

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2
3
4
5
6
7
8
9
10
11
12
13

On 5/11/22 at 9:40am., Licensing Program Analyst (LPA) Haydee Caliboso arrived at the facility to conduct a 10-day complaint inspection in response to the above allegation(s). LPA met with Site Supervisor, Nicole Porter. Present during the inspection were 27 preschool-aged children, 8 staff, and Director.

Based on LPA's gathered information through observations and interviews with staff, the agency has investigated the complaint allegation(s) above. Child fell, and sustained injury while in care, however, Staff did not notify parents of the injury in a timely manner. The preponderance of evidence standard has been met. Therefore, the above allegation(s) is closed and found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12 & Chapter 1, are being cited on the attached LIC 9099D

This report will be kept in the Facility File and will be made available for Public Review upon request. Website for Forms and Regulations: www.ccld.ca.gov. Appeal Rights were given, explained, and provided to the facility. This report and rights to comment and appeal have been discussed. A Notice of Site Visit was posted during this inspection.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 05-CC-20220506172359

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: NORTH BAY CHILDREN'S SCHOOL	FACILITY NUMBER: 214005479
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/11/2022 Section Cited HSC 101226(a)(2)	1 2 3 4 5 6 7	101226(a)(2)Health-Related Services a) The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch. The licensee shall obtain specific instructions from the authorized representative regarding action to be taken. (2) In the case of less serious injuries including, but not limited to, minor cuts, scratches and bites from other children requiring assessment and/or administration of first aid by staff, the licensee shall document the injury in the child's record and notify the child's authorized representative of the nature of the injury when the child is picked up from the center.	1 2 3 4 5 6 7	Program will contact/notify the parents and or authorized representatives of the child of any incident/injury while chlidren are in care in a timely manner to ensure child did not need medical attention effectively 5/11/22.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on observations and interviews with staff and child’s parent on 5/11/22, Staff did not notify parents or child’s authorized representatives of child’s incident/injury in a timely manner to ensure child did not need medical attention. This poses a potential risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Haydee R Caliboso
LICENSING EVALUATOR SIGNATURE:	DATE: 05/11/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022

LIC9099 (FAS) - (06/04)

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