<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313623338
Report Date: 10/11/2023
Date Signed: 10/11/2023 12:30:31 PM

Document Has Been Signed on 10/11/2023 12:30 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MERRYHILL SCHOOL - ROCKLINFACILITY NUMBER:
313623338
ADMINISTRATOR:MELISSA MOENNINGFACILITY TYPE:
850
ADDRESS:5893 STANFORD RANCH ROADTELEPHONE:
(916) 624-4511
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 156TOTAL ENROLLED CHILDREN: 156CENSUS: 94DATE:
10/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Melissa MoenningTIME COMPLETED:
12:40 PM
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
Licensing Program Analyst (LPA) Jeremey McClain met with facility representative for an unannounced Case Management Inspection regarding an Unusual Incident Reported received via email on 10/05/2023.

LPA observed 94 children supervised by 11 staff members.

It was reported that on 10/02/2023, Child #1 was using the restroom while during outdoor play. Staff #1 sent Child #1 to Staff #2, who was at the playground adjacent to Staff #1. Staff #2 supervised Child #1 at the bathroom that can be entered through from the playground. During this time Staff #1 stood at the gate that joins the playgrounds while she also supervised the remaining children on the playground. Staff #2 closed the door while the child was still in the bathroom after they thought they saw the child come out of the bathroom. Staff #1 immediately recognized that the child was not back, and asked the staff to check the bathroom again, where the child was found. The child did not suffer any injuries. It was estimated that the child was left alone in the bathroom for no longer than a minute. This incident was self-reported by the facility, and the child’s parents were notified immediately.

Deficiencies are cited on the following page of this report, and if not corrected, pose a potential threat to the health and safety of children in care.

This report was reviewed with facility representative Melissa Moenning. LPA provided a Notice of Site Visit, which must remain posted for 30 days.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/11/2023 12:30 PM - It Cannot Be Edited


Created By: Jeremey McClain On 10/11/2023 at 12:16 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MERRYHILL SCHOOL - ROCKLIN
FACILITY NUMBER: 313623338

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2023
Section Cited
CCR
101229(a)(1).

1
2
3
4
5
6
7
Responsibility for Providing Care and Supervision. (1)No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.
This requirement was not met as evidenced
1
2
3
4
5
6
7
Staff was placed on aministrative leave in order for the facility to conduct an investigation. Staff were retrained on supervision. Staff now follow new procedures when children have to use the bathroom while using the playground.
8
9
10
11
12
13
14
by the unusual incident report, which was reported to LPA on 10/03/2023. Child #1 was left in the bathroom on the playground with the door closed for approximately 1 minute. The child was not injured. This is a potential risk to the health and safety of 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.
SUPERVISOR'S NAME:Keven Peters
LICENSING EVALUATOR NAME:Jeremey McClain
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2