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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009809
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:15:19 PM

Document Has Been Signed on 04/10/2025 04:15 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:L'ACADEMY PRESCHOOL FAIRFIELDFACILITY NUMBER:
483009809
ADMINISTRATOR/
DIRECTOR:		NOEMI GOMEZFACILITY TYPE:
850
ADDRESS:5150 WISEMAN WAYTELEPHONE:
(707) 639-3773
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 98TOTAL ENROLLED CHILDREN: 98CENSUS: 51DATE:
04/10/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:52 AM
MET WITH:Noemi GomezTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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An unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Selena Mariani in response to a self-reported, lack of supervision incident involving a child C1 and five staff, S1-S5. The incident occurred on 03/27/25. During today’s visit, the LPA met with Center Director Noemi Gomez to discuss the incident, obtained documents, conducted interviews with Center Director, three staff (S1-2 and S6) and one parent (P2). LPA attempted interviews with two parents (P1 and P3).

It was reported on 04/01/25 by Center Director (CD) Noemi Gomez that on 03/27/25, a child C1 exited the front gate of the facility unnoticed by staff as families were coming in and out for pickup. CD reported that 5 staff S1-S5 were supervising children on the playground at approximately 4:30 pm and 30 children were signed out on 2/27/25 between 4:21 pm to 5:08 pm. P2 stated while opening the gate, C1 ran out of the play yard to the sidewalk. P2 further stated following after C1 so C1 wouldn't go in to the parking lot, it happened with in a few seconds, C1 didn't get far and stayed on the side walk. P2 called out to S1 who immediately went out to get C1. S1 and S2 stated that C1 was not crying or in distress. P2 stated, "I don't have concerns about the preschool."

This self-reported incident was reported to CCLD as required per regulations. CD reported that this incident was also reported to the child’s (C1’s) authorized representative. CD reported discussing with the teachers the importance of active supervision and assigning a teacher to supervise at the gate especially at pick up time. CD stated researching and installing either an additional or different locking system for the gate. During today’s case management visit, no children were observed to be left without supervision. LPA interviewed CD who was able to explain what went wrong and how the new procedure in place will prevent the incident from re-occurring.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Selena Mariani
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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 4
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)
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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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: L'ACADEMY PRESCHOOL FAIRFIELD
FACILITY NUMBER: 483009809
VISIT DATE: 04/10/2025
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Continue from LIC809

Based on available information, it has been determined that staff S1-S5 did not provide adequate supervision to child C1 during the incident on 03/27/2025. The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D.

This report was read and reviewed with facility representative Center Director, Noemi Gomez.

Notice of site visit shall be posted for 30 days. Appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Selena Mariani
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/10/2025 04:15 PM - It Cannot Be Edited


Created By: Selena Mariani On 04/10/2025 at 02:37 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: L'ACADEMY PRESCHOOL FAIRFIELD
FACILITY NUMBER: 483009809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2025
Section Cited
CCR
101229(a)(1)

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Care and Supervision. 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 by:
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LPA provided CD "Active Supervision At-A-Glance" material. CD will conduct a staff meeting on 4/18/25. CD will reseach and install different locking device for the play yard gate. CD will email LPA proof of staff attendance and meeting minutes to Selena.Mariani@dss.ca.gov

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Based on CD's written unusual incident report (UIR) submitted to CCLD on 04/01/25, stating that on 03/27/25 at approximately 4:30 pm, child C1was without supervision of a teacher for approximately a few seconds minutes while C1 exited through the play yard gate and was on the sidewalk of the preschool parking lot which posed a potential health and safety risk to a child 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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Selena Mariani
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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