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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493001830
Report Date: 10/27/2023
Date Signed: 10/27/2023 03:34:17 PM


Document Has Been Signed on 10/27/2023 03:34 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:KINDERCARE LEARNING CENTERFACILITY NUMBER:
493001830
ADMINISTRATOR:PEPPER, ALEXANDRIAFACILITY TYPE:
830
ADDRESS:6150 STATE FARM DRIVETELEPHONE:
(707) 584-0124
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:40CENSUS: 11DATE:
10/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Alexandria "Alex" PepperTIME COMPLETED:
03:22 PM
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A Case Management inspection was conducted at the facility by Licensing Program Analyst (LPA) Y. Yang in response to an Unusual Incident Report (UIR) received 10/12/2023 involving a child sustaining an injury while in care. The center director, Alexandria Pepper reported that on 10/11/23, child C1 was playing on the infant/toddler play yard with six other children and being supervised by staff S1 and S2. Pepper reported that the child was pushing a plastic balance bike on the concrete surface of the playground and lost their balance as the bike transitioned from the concrete surface to the soft grass that was adjacent to the playground. Pepper reported that the child bumped their mouth on the bike causing the child to bleed from their mouth. Pepper reported that the child was transported to be seen by a medical professional. Pepper reported that there was no further medical treatment required. This incident was reported to CCLD as required per regulations.

During today's case management visit, the LPA reviewed with the center director the facility's child supervision policies and made best practice recommendations to the center director regarding the physical plant at the facility. Pepper stated that since the incident, the center’s maintenance person used topsoil to reduce the height of the grass and create a semi-flush transition between the concrete and the grass.

Based on available information, it has been determined that there was no evidence of violations of regulations that occurred that lead to the child's injury. This report was read and reviewed with the center director, Alex Pepper. There were no Title 22 violations cited. The Notice of Site Visit shall be posted for 30 days.

SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Yang YangTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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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