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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009256
Report Date: 06/09/2026
Date Signed: 06/09/2026 04:04:01 PM

Document Has Been Signed on 06/09/2026 04:04 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MARY BIRD EARLY CHILDHOOD EDUCATION CENTERFACILITY NUMBER:
483009256
ADMINISTRATOR/
DIRECTOR:		KIMBERLY HATHAWAYFACILITY TYPE:
850
ADDRESS:420 EAST TABOR AVENUETELEPHONE:
(707) 438-3684
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY: 288TOTAL ENROLLED CHILDREN: 288CENSUS: 19DATE:
06/09/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:10 PM
MET WITH:Kimberly HathawayTIME VISIT/
INSPECTION COMPLETED:
04:13 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
An unannounced case management visit was made to the facility today by Licensing Program Analyst (LPA) Jessica Gaumann in response to a self-reported Unusual Incident Report (UIR) which was reported to the Department on 06/08/2026. During today’s follow-up visit, LPA met with Director (D1), Kimberly Hathaway.

It was reported that on 06/01/2026, a child (C1) became stuck inside a pipe on the grass area on the playground. D1 and staff interviews (S1 and S2) revealed that no staff member observed the incident occur. D1 and S1 verified no staff member observed the incident by reviewing video footage from the facility on that date.

LPA Jessica Gaumann informed facility representative, Kimberly Hathaway, that this report dated 06/09/2026 document(s) one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Jessica Gaumann informed the facility representative, Kimberly Hathaway, to provide a copy of this licensing report dated 06/09/2026 that documents any Type A citation(s) 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.

The following violation of California Code of Regulations, Title 22, was cited on the attached LIC 809-D page. A notice of site visit was given and must remain posted for 30 days. Appeal rights were provided. Exit interview conducted and report was reviewed with Director, Kimberly Hathaway.

NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr
NAME OF LICENSING PROGRAM ANALYST: Jessica Gaumann
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/09/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2026
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 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
Document Has Been Signed on 06/09/2026 04:04 PM - It Cannot Be Edited


Created By: Jessica Gaumann On 06/09/2026 at 03:21 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MARY BIRD EARLY CHILDHOOD EDUCATION CENTER
FACILITY NUMBER: 483009256

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2026
Section Cited
CCR
101229(a)(1)

1
2
3
4
5
6
7
101229 (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...Supervision shall include visual observation.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Director (D1) stated that maintenance bolted down previously latched irrigation boxes and inspected all remaining irrigation and sewage access points throughout the facility before students arrived on 06/02/26 and held a staff meeting that reviewed expectations of supervision and zoning in accordance with the already established playground zone
8
9
10
11
12
13
14
Based on interviews conducted it has been determined that facility staff failed to provide adequate supervision resulting in a child (C1) getting stuck in a pipe on the playground, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
maps that same day. D1 stated she will submit a written statement including the policy changes that have been implemented and details of the 06/02/26 training to LPA Gaumann via email: jessica.gaumann@dss.ca.gov

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.
Melinda Mohr
NAME OF LICENSING PROGRAM MANAGER:
Jessica Gaumann
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/09/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2026


LIC809 (FAS) - (06/04)
Page: 3 of 3