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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371103
Report Date: 08/19/2021
Date Signed: 08/19/2021 12:58:12 PM

Document Has Been Signed on 08/19/2021 12:58 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GODDARD SCHOOL, THEFACILITY NUMBER:
304371103
ADMINISTRATOR:IRVING, JENNIFERFACILITY TYPE:
850
ADDRESS:20455 ALTON PARKWAYTELEPHONE:
(949) 393-1220
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 115TOTAL ENROLLED CHILDREN: 0CENSUS: 92DATE:
08/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Director, Jennifer IrvingTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cindy Nguyen conducted an unannounced case management inspection in response to a self reported incident. LPA met with Assistant Director, Julie Koclanis who guided LPA on a tour of the facility. LPA observed 92 preschool age children with 13 staff members. During today's inspection staffing and capacity ratios were met. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

On 07/30/2021 an unusual Incident Report (UIR) was filed with the Licensing Office. The facility reported that on 07/30/2021, around 9:50am, the classroom was coming in from outside time. The classroom lined up outside the classroom door by the fence. Staff #1 (S1) was counting the children while doing name to face seeing each child walking into the classroom. One of the last children in line was Child #1 (C1). S1 called C1 name and saw C1 and thought C1 went into the classroom, however, C1 went behind the open classroom door. S1 counted the children, however they were moving inside and into the bathroom line. All the children had arrived late in the classroom and many of them had to use the restroom at the same time. So, in the rush of help the other children, S1 started to head to the bathroom to help. A few seconds later as S1 reached the bathroom, they heard a knock. Staff #2 (S2) ran quickly to the back door and saw C1 at the door.



During today's inspection, LPA interviewed 3 staff members, and conducted a physical plant inspection. Based on the information gathered from documentation and interviews conducted, it was determined that Child #1 was outside when the door closed, immediately S1 & S2 heard a knock at the door, S2 immediately open the door and found C1.

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SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GODDARD SCHOOL, THE
FACILITY NUMBER: 304371103
VISIT DATE: 08/19/2021
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The facility representatives stated we have discussed with and reminded teachers how to position themselves so that a child can't go behind the door and how to watch to make sure a child walks all the way into the classroom. The facility has also added another strategy of the children counting themselves while they walk into the transition area, in addition, to the staff protocol of name to face.

California Code of Regulations, Title 22, Division 12, Chapter 1, Section 101229(a)(1) is being cited on the attached LIC 809D. A civil penalty of $500 has been assessed during today's inspection.

This report cites Type A violation and shall be provided to parents/guardians of children currently in enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC9224 to be kept in each child's file.



Exit interview was conducted with Director, Jennifer Irving. Notice of Site Visit was posted during the inspection. Facility representatives was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Facility representatives was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/19/2021 12:58 PM - It Cannot Be Edited


Created By: Cindy Nguyen On 08/19/2021 at 11:44 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: GODDARD SCHOOL, THE
FACILITY NUMBER: 304371103

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/20/2021
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1). This requirement was not met as evidenced by:
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The facility representatives stated we have discussed with and reminded teachers how to position themselves so that a child can't go behind the door and how to watch to make sure a child walks all the way into the classroom. A signed acknowledgment email to LPA Nguyen (Cindy.Nguyen@dss.ca.gov) by 08/20/21.
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Based on the information gathered from documentations and interviews conducted, it was determined that Child #1 was outside when the door closed, immediately S1 & S2 heard a knock at the door, S2 immediately open the door and found C1. This poses an immediate health and safety risk to children in care
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A civil penalty of $500 has been assessed during today's inspection.

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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:Judy Hanson
LICENSING EVALUATOR NAME:Cindy Nguyen
LICENSING EVALUATOR SIGNATURE:
DATE: 08/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/19/2021


LIC809 (FAS) - (06/04)
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