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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233002483
Report Date: 05/07/2024
Date Signed: 05/07/2024 12:00:59 PM

Document Has Been Signed on 05/07/2024 12:00 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:NCO HEAD START - CHILD DEV. CTR. - NOKOMISFACILITY NUMBER:
233002483
ADMINISTRATOR/
DIRECTOR:		ANNA CRUMPLERFACILITY TYPE:
850
ADDRESS:499 WASHINGTON AVE.TELEPHONE:
(707) 462-2671
CITY:UKIAHSTATE: CAZIP CODE:
95482
CAPACITY: 60TOTAL ENROLLED CHILDREN: 36CENSUS: 32DATE:
05/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:07 AM
MET WITH:Anna CrumplerTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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An unannounced Case Management visit was made to the facility by Licensing Program Analyst (LPA) Robert Maciel to address an incident that was brought to attention of the Department during a complaint investigation. According to interviews with staff and adults conducted on 5/7/24, there was an unreported unusual incident that occurred on 5/1/24 regarding the gas knob on a kitchen stove being turned on by accident and releasing enough gas into the facility to where staff and adults could smell it. Interviews reveal that staff who directly observed or later became aware of the incidents did not report it to the Department verbally or by fax by the next working day.

The following deficiency is being cited (see LIC 809D). Appeal Rights were 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 Director, Anna Crumpler.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2024
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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Document Has Been Signed on 05/07/2024 12:00 PM - It Cannot Be Edited


Created By: Robert Maciel On 05/07/2024 at 11:36 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NCO HEAD START - CHILD DEV. CTR. - NOKOMIS
FACILITY NUMBER: 233002483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2024
Section Cited
CCR
101212(d)(1)(C)

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101212 ...during the operation of the child care center if any of the events specified in (d)(1) below, a report shall be made to the Department by… next working day... In addition, a written report…shall be submitted to the Department within seven days...(1)Events reported shall include the following: (C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.
This requirement was not met as evidenced by:
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Facility policy has already been updated to include any incident involving gas and LPA observed the director submit a written UIR to the department.
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Based on interviews, staff who directly observed or later became aware of the incident on 5/1/24 did not report it to the Department within the next working day. This poses a potential health, safety or personal rights risk to persons 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:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024


LIC809 (FAS) - (06/04)
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