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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500231
Report Date: 11/22/2022
Date Signed: 11/23/2022 01:51:23 PM

Document Has Been Signed on 11/23/2022 01:51 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 SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:CAPC - STELLA BROCKMANFACILITY NUMBER:
394500231
ADMINISTRATOR:ROBLES, DENISEFACILITY TYPE:
850
ADDRESS:763 SILVERADO DRTELEPHONE:
(209) 851-3479
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 14DATE:
11/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Site Supervisor, Makayla Hannah and
Lead Teacher, Nesia Osorio		TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Lauren Scott and Tobias Lake met with Site Supervisor, Makayla Hannah, and Lead Teacher, Nesia Osorio, to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 11/8/2022. The facility reported the UIR to Community Care Licensing within 24hrs. A written UIR was submitted within 7 days, describing the specifics of the incident. During today's visit the facility was toured. Present were 14 school age children in care and 3 staff.

LPAs interviewed the Site Supervisor and Lead Teacher who were present during the incident. LPAs reviewed and discussed this report with the Site Supervisor and Lead Teacher. Lead Teacher stated two children were on top of the play structure and ran into each other, causing one child's tooth to dislodge. The child was taken to the doctor and dentist. The child was instructed to stay home for 14 days by the doctor due to the inability to eat solid foods. LPA requested a copy of the doctor report, Site Supervisor stated she would ask the parents for it.

LPAs conducted an observation of the play structure and outside area. Upon inspection, LPA saw the sign on the play structure that stated ages 5-12. LPA reviewed the facility's files and their prelicensing visit that was conducted in June 2020. The prelicensing inspection report states the children are not allowed to use this play structure. Although the facility has a shared outdoor space waiver, it states all staff will ensure that children are using age appropriate equipment at all times.

Facility evaluation report was reviewed and discussed with Site Supervisor and Lead Teacher. Exit interview was conducted. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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 11/23/2022 01:51 PM - It Cannot Be Edited


Created By: Lauren Scott On 11/22/2022 at 03:38 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: CAPC - STELLA BROCKMAN
FACILITY NUMBER: 394500231

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/22/2022
Section Cited
CCR
101223(a)(2)

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personal rights (a)The licensee shall ensure that each child is accorded the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement was not met as evidenced by
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Facility is making the play structure off limits immediately. Staff will be using signs in the entrances of the play structure, preventing children from entering. Staff will be supervising the area and preventing children from entering as well.
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Children were allowed to use the play structure that was not licensed for the facility, stating it is only for the school age children (ages 5-12) with whom they share a outdoor space with.
This is an immediate health and safety risk to children in care.
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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:Chayntel Hunter
LICENSING EVALUATOR NAME:Lauren Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


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
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: CAPC - STELLA BROCKMAN
FACILITY NUMBER: 394500231
VISIT DATE: 11/22/2022
NARRATIVE
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LPA Scott informed Site Supervisor, Mikayla Hannah, and Lead Teacher, Nesia Osorio, that this report dated November 22, 2022 documents one Type A citations which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Scott informed the Site Supervisor and Lead Teacher to provide a copy of this licensing report dated November 22, 2022 that documents any Type A citations to parents/ guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
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