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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343605844
Report Date: 11/02/2022
Date Signed: 11/02/2022 09:57:54 AM

Document Has Been Signed on 11/02/2022 09:57 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:NORTHWOOD CHILD DEVELOPMENT CENTERFACILITY NUMBER:
343605844
ADMINISTRATOR:KHAMNIVONG, FONGFACILITY TYPE:
850
ADDRESS:2630 TAFT STREETTELEPHONE:
(916) 229-4530
CITY:SACRAMENTOSTATE: CAZIP CODE:
95815
CAPACITY: 72TOTAL ENROLLED CHILDREN: 72CENSUS: 17DATE:
11/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jessica MohammadTIME COMPLETED:
10:15 AM
NARRATIVE
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On 11/2/2022, Licensing Program Analyst (LPA) Alize Tillery, met with Administrator Megan Simmons and Director Jessica Mohammad, for the purpose of an unannounced Case Management inspection. Upon arrival, there were 17 children supervised by 4 staff.

The regional office received an Unusual Incident Report that occurred on 10/24/2022. Director self-reported the incident to the Regional Office via telephone call to the Officer of the Day on 10/25/22 and via Unusual Incident Report (UIR). LPA learned that a child was left unattended inside the classroom for approximately 5 minutes.

Staff interviews revealed that Staff #1, gave Child #1 permission to get water inside the classroom. Child #1 was found unattended by Director. Director stated that she has since had conversation with all staff regarding their supervision policy and practices.

Based on interviews conducted and information from the self-reported incident, it has been determined that there was a lack of supervision. Deficiency is listed on the following 809D page.


Director acknowledges, that for TYPE A DEFICIENCIES ONLY upon receipt, Director shall post LIC 809-D with Type A deficiency for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the Licensees. LIC9224 and Appeal Rights were provided. An exit interview was conducted and a Notice of Site Visit posted.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Alize Tillery
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2022
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 11/02/2022 09:57 AM - It Cannot Be Edited


Created By: Alize Tillery On 11/02/2022 at 09:46 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
, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: NORTHWOOD CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 343605844

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2022
Section Cited
CCR
101229(a)(1)

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(a) The licensee shall provide care and supervision as necessary to meet the children's needs.
(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.
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Director will conduct trainings with staff regarding Supervision. Director will submit proof to LPA Tillery.
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This requirement was not met, evidenced by:
The unusual incident report and staff interviews revealed that Child #1 was left unattended inside the classroom for approximately 5 minutes, Child #1 was found by the Director, unattended.
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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:Seychelle De Luca
LICENSING EVALUATOR NAME:Alize Tillery
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022


LIC809 (FAS) - (06/04)
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