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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483009809
Report Date: 07/19/2023
Date Signed: 07/19/2023 11:18:53 AM

Document Has Been Signed on 07/19/2023 11:18 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:L'ACADEMY PRESCHOOL FAIRFIELDFACILITY NUMBER:
483009809
ADMINISTRATOR:SABRINA OLDANIFACILITY TYPE:
850
ADDRESS:5150 WISEMAN WAYTELEPHONE:
(707) 639-3773
CITY:FAIRFIELDSTATE: CAZIP CODE:
94534
CAPACITY: 98TOTAL ENROLLED CHILDREN: 98CENSUS: 13DATE:
07/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Noemi Gomez, DirectorTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA), Selena Mariani conducted an unannounced case management inspection and met with Director (D1) Noemi Gomez. On 7/14/2023, facility self-reported an incident which occurred on 7/13/2023 at approximately 11:50 am in which Staff 1 (S1) grabbed the back collar of Child 1's (C1's) shirt resulting in injury to the front of C1’s neck.

Title 22 deficiency is being cited on the attached 809-D, civil penalty applies.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.


LPA Mariani informed D1 to provide a copy of this licensing report dated 07/19/23 that documents a Type A citation 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.

Exit interview was conducted, report was reviewed, and Appeal Rights were provided to the Director, Noemi Gomez.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Selena Mariani
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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 07/19/2023 11:18 AM - It Cannot Be Edited


Created By: Selena Mariani On 07/19/2023 at 09:37 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
, 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: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2023
Section Cited
CCR
101223(a)(3)

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Personal Rights:(a)The licensee shall ensure that each child is accorded the following personal rights:(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living
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Director (D1) stated S1 will read Personal Rights 101223(a)(3) Regulations and watch the California Department of Social Services video on Children's Personal Rights. S1 will sign and date document stating acknowlegement and understanding of Children's personal Rights and D1 will submit
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including eating, sleeping or toileting; or withholding of shelter, clothing,medication or aids to physical functioning.This requirement is not met as evidenced by: Based on the Unusual Incident Report submitted by the facility on 7/13/2023, reporting that Staff 1 injured Child 1. This poses an immediate health and safety risk to the children in care.
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by email to LPA Mariani.

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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:Alexis Hollon
LICENSING EVALUATOR NAME:Selena Mariani
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
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