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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110022
Report Date: 10/28/2026
Date Signed: 10/28/2026 04:32:59 PM

Document Has Been Signed on 10/28/2026 04:32 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:A SPECIAL PLACEFACILITY NUMBER:
490110022
ADMINISTRATOR/
DIRECTOR:		ERIKA ARAIZAFACILITY TYPE:
850
ADDRESS:1128 EDWARDS AVENUETELEPHONE:
(707) 523-2337
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 30TOTAL ENROLLED CHILDREN: 0CENSUS: 15DATE:
10/28/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Erika AraizaTIME VISIT/
INSPECTION COMPLETED:
04:47 PM
NARRATIVE
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On 10/28/26, Licensing Program Analyst (LPA), Amy Strother made an unannounced Case Management visit in response to a self-reported, lack of supervision Unusual Incident Report (UIR). Community Care Licensing received a UIR notification on 10/22/26. The incident was regarding a child being unsupervised inside the classroom after a transition from the bathroom to outside. LPA met with Site Supervisor, Erika Araiza (D1) to discuss the purpose of today's visit.

During today's inspection, LPA toured the facility inside and out and observed 15 children being supervised by 4 staff members. LPA conducted an interview with D1. D1 stated transition procedures were not followed when child (C1) was left unsupervised in the secure classroom, while using the bathroom. The statements in the UIR were corroborated by interviews with D1. The incident included five day care children using the twos bathroom in the main classroom with staff S1. S1 was with 4 children in one of the bathrooms, while child C1 was in the other bathroom. S1 then transitioned the group outside, leaving C1 in the bathroom unattended. After finishing in the bathroom, C1 went to the kitchen area where D1 was cleaning up from snack, behind a half door. D1 took C1 outside to join the group and spoke to S1 about what had happened.

Additionally, D1 stated, as stated in the UIR, that the transition protocol was reviewed with all staff and was then discussed at the staff meeting on 10/23/26 to talk about transitions and the importance of doing visual sweeps and head counts. D1 stated that staff shout out numbers during transitions the other teacher say the number back. D1 stated that they also talked about, when taking children to the bathroom staff are to let the other staff know how many children they are taking and having them repeat it back. D1 stated that they also talked about using walkie-talkies as an option for communication.

Continue LIC809-C

Melchisedeck Augustin
Amy Strother
DATE: 10/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2026
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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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: A SPECIAL PLACE
FACILITY NUMBER: 490110022
VISIT DATE: 10/28/2026
NARRATIVE
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During today’s visit, LPA observed 15 children on the playground with 4 staff. A parent arrived for pick-up and S1 went to white board hanging in the yard and changed the number from 15 to 14, calling out to the three other staff, “We have 14.” The staff all repeated, “We have 14.” , this was observed again when the numbers went from 14 to 13.

During the tour of the bathroom, LPA observed that it is not possible for one teacher to see into both bathrooms at the same time. LPA and D1 discussed possible solutions for achieving supervision requirements when only one teacher can be present in the main classroom.

The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC809 D. Appeal rights were given.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Site Supervisor, Erika Araiza.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Amy Strother
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2026 04:32 PM - It Cannot Be Edited


Created By: Amy Strother On 10/28/2026 at 04:12 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: A SPECIAL PLACE
FACILITY NUMBER: 490110022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/13/2026
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision....(1) No child(ren) shall be left without the supervision of a teacher at any time,...

This requirement was not met as evidenced by:
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D1 stated the transition protocol was reviewed with all staff on 10/22/26, and that transitions and the importance of sweeping the yard (or classroom) and doing a head count were discussed at the Friday staff meeting on 10/23/26.
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Based on the facility's admission of a self-reported Unusual Incident Report (UIR) notification on 10/22/2026, a child (C1) was left unsupervised for 2-3 minutes located in the classroom bathroom, a secured area of the facility, posing a potenial which health, safety or personal rights risk to persons in care.
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D1 will submit an outline of what was discussed during the meeting and provide staff attendance with signatures, as well as proof of creating a classroom environment where only one bathroom is in use, when only one staff is present in the room or a plan for how both bathrooms can be supervised by one staff. POC to be submitted to LPA Strother’s email: amy.strother@dss.ca.gov

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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:
Amy Strother
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2026


LIC809 (FAS) - (06/04)
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