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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393604766
Report Date: 11/10/2021
Date Signed: 11/10/2021 11:00:57 AM

Document Has Been Signed on 11/10/2021 11:00 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:CATALYST KIDS - WANDA HIRSCHFACILITY NUMBER:
393604766
ADMINISTRATOR:RODRIGUEZ, MARIAFACILITY TYPE:
840
ADDRESS:1280 DOVE STREETTELEPHONE:
(209) 836-0977
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY: 70TOTAL ENROLLED CHILDREN: 70CENSUS: 0DATE:
11/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Maria Rodriguez TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Stacey Williams met with Assistant Site Supervisor, Maria Rodriguez to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 10/28/2021. During today's inspection the facility was toured. There were no school age children present.

LPA interviewed the Assistant Site Supervisor. Assistant Site Supervisor confirmed that she was the only staff working when the incident occurred. The interview conducted revealed that a child (C1) was left in the facility while staff took kindergarten students to the on site elementary school. C1 did not notify staff they needed to use the restroom and left the line without staff noticing. C1 was out of staff's line of sight for approximately 3 minutes. Based on the information obtained LPA determined C1 was left unattended.

The facility reported the unusual incident report (UIR) to Community Care Licensing and submitted a written UIR, describing the specifics of the incident. The Assistant Site Supervisor stated they have policy and training modules on supervision and transitions for all staff to review. Assistant Site Supervisor will also conduct a staff meeting to discuss Title 22 regulations regarding supervision and zoning.

Facility evaluation report was reviewed and discussed with Site Supervisor. The following Title 22 Deficiency is being cited on the subsequent 809-D page. Upon receipt of Type A citations, licensee shall post and provide copies of the LIC 809-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 809-D in each child's file. LPA reviewed and discussed this report with the Assistant Site Supervisor. Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2021
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 11/10/2021 11:00 AM - It Cannot Be Edited


Created By: Stacey Williams On 11/10/2021 at 10:40 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: CATALYST KIDS - WANDA HIRSCH
FACILITY NUMBER: 393604766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/11/2021
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision
(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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Assistant Site Supervisor stated they have policy and training modules on supervision and transitions for all staff to review. Assistant Site Supervisor will also conduct a staff meeting to discuss Title 22 regulations regarding supervision and zoning.
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This requirement was not met as evidenced by: Community Care Licensing was notified by staff that C1 was left in the facilty unattended for approximately 3 minutes while staff took kindergarteners to class onsite at the elementary school. This poese an immediate risk to the health and safety of children in care.
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Civil Penalty assessed.

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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:Bettina Engelman
LICENSING EVALUATOR NAME:Stacey Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021


LIC809 (FAS) - (06/04)
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