233004124-9-24-2026-01-CC-RMAL-DY8PLA-20260924112425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 233004124
Report Date: 09/24/2026
Date Signed: 09/24/2026 11:24:33 AM

Document Has Been Signed on 09/24/2026 11:24 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	BROOKSIDE PRESCHOOL		FACILITY NUMBER:	233004124
ADMINISTRATOR/ DIRECTOR:	CHELSEA RODRIGUEZ		FACILITY TYPE:	850
ADDRESS:	SPRUCE AND LINCOLN WAY		TELEPHONE:	(707) 459-5385
CITY:	WILLITS	STATE: CA	ZIP CODE:	95490
CAPACITY: 20	TOTAL ENROLLED CHILDREN: 13	CENSUS: 5	DATE:	09/24/2026
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:05 AM
MET WITH:	Chelsea Rodriguez		TIME VISIT/ INSPECTION COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	A Case Management visit was conducted at the facility by Licensing Program Analyst (LPA) Robert Maciel-Kashima in response to a self-reported Unusual Incident Report received by the department on 8/20/26 regarding a child (C1) who was left on the playground during transition inside. LPA met with Site Supervisor Chelsea Rodriguez. According to the incident report, at around 10:00 am on 8/23/26, a staff member (A1) from the Brookside Elementary School dropped off a student (C2) from Brookside Elementary School who was not enrolled at the facility. A1 left the facility, leaving C2 on the facility playground, bringing the total number of children at the facility from 11 to 12. 2 children were already inside the facility so when staff were counting children to transition indoors, they accounted for the presumed 9 remaining children outside and went indoors. While staff and children were entering the classroom, a practice fire alarm went off. Staff from the adjacent facility, NCO Willits Early Head Start (#233003724) were practicing evacuation and noticed a child (C1) on the playground and alerted facility staff who retrieved them. During today's visit, LPA observed 5 children being supervised by 3 staff. LPA interviewed Site Supervisor who stated that they have since spoken with A1 and clarified that all children present on site must be enrolled at the facility. Additionally, Site Supervisor stated that C2 has since enrolled at the facility and that their transition policy is to perform head counts of children before transitioning and again at the playground gates during the line-up before entering the classroom. No deficiencies were observed during today's visit. Appeal rights were provided. Report was reviewed and read to the Site Supervisor Chelsea Rodriguez. A notice of site visit was given and must remain posted for 30 days. Failure to do so shall result in an immediate civil penalty of $100.

Melchisedeck Augustin
Robert Maciel
	DATE: 09/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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