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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490105414
Report Date: 02/01/2022
Date Signed: 02/01/2022 02:30:03 PM

Document Has Been Signed on 02/01/2022 02:30 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BRUSH CREEK FAMILY SERVICES, INC.FACILITY NUMBER:
490105414
ADMINISTRATOR:MAC DONALD, JULIEFACILITY TYPE:
850
ADDRESS:4657 BADGER ROADTELEPHONE:
(707) 539-1612
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 20DATE:
02/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Julie MacDonaldTIME COMPLETED:
01:25 PM
NARRATIVE
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A Case Management visit was conducted at the facility by LPA Trinh in response to an Unusual Incident Report received August 26, 2021 involving a lack of supervision. LPA met with Director, Julie MacDonald (D1). According to the incident report and interviews conducted, sometime between 2:45 pm- 2:50 pm on August 25, 2021 a 3 year old child (C1) was playing in the playground. C1 pushed open gate, walked into parking lot, and started to walk down the driveway and was discovered by a PG&E worker who called D1.
Interviews support that it was the second day of school, C1 involved in the incident managed to leave the playground while two teachers were watching 11 children. Interviews corroborate C1 was returned to the playground at around 2:50 pm. C1 was unsupervised for 3 to 4 minutes. D1 stated that when PG&E worker called her to report C1 was seen, it was the same time Teacher spotted C1. During today’s visit there were 20 children accounted for and being supervised by 5 staff. Based on available information, it has been determined that preschool staff were not properly supervising C1 when the incident occurred on August 25, 2021.
The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D.
Notice of site visit must be posted for 30 days. Reports citing Type A violations are to be provided to parents/guardians of children currently enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC 9224 to be kept in each child's file. Appeal rights provided during visit.
This report is amended from LIC809 dated on 09/15/2021 due to LIC809D not given.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Mary Trinh
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2022
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 02/01/2022 02:30 PM - It Cannot Be Edited


Created By: Mary Trinh On 02/01/2022 at 12:55 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: BRUSH CREEK FAMILY SERVICES, INC.
FACILITY NUMBER: 490105414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2022
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing 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.
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1. Have all staff meeting about procedures and policies of Supervision. Staff meetings are every wed morning.
2. Installed second latch on gate.
3. Meeting with Parent of C1 which was 08/27/2021.
4. Inform all Parents of what happened in newsletter.
Notes of the staff meeting (09/01/2021) will be emailed to LPA Trinh by 02/03/2022.
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This requirement was not met as evidenced by: the Director UIR on 08/25/21 stated C1 was left without supervision of a teacher for 3-4 minutes when children were playing in the playground. This presents a potential threat to the health and safety of 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:Alexis Hollon
LICENSING EVALUATOR NAME:Mary Trinh
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2022


LIC809 (FAS) - (06/04)
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