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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493004498
Report Date: 06/04/2024
Date Signed: 06/04/2024 12:16:43 PM

Document Has Been Signed on 06/04/2024 12:16 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:WINDSOR CHRISTIAN ACADEMY - P/SFACILITY NUMBER:
493004498
ADMINISTRATOR/
DIRECTOR:		O'MALLEY, DAWNFACILITY TYPE:
850
ADDRESS:10285 STARR ROADTELEPHONE:
(707) 838-3084
CITY:WINDSORSTATE: CAZIP CODE:
95492
CAPACITY: 109TOTAL ENROLLED CHILDREN: 59CENSUS: 40DATE:
06/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:42 AM
MET WITH:Dawn O'MalleyTIME VISIT/
INSPECTION COMPLETED:
11:28 AM
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An unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang in response to a self reported incident involving child C1. During today’s visit, the LPA met with the center director, Dawn O'Malley to discuss the incident.

It was reported by center director O'Malley that on 05/21/24, while on the center's main preschool playground, child C1 tripped and fell while playing with a ball; hitting their nose on the concrete floor. Director O'Malley stated that first aid was provided and the child's authorized representative was notified. Director O'Malley stated that the child's authorized representative transported the child to be examined by a medical professional on 05/23/24 after the child showed symptoms of a concussion. Director O'Malley reported that the child sustained a mild concussion and possible broken nose. During today's case management visit, the LPA inspected the playground and did not observe any evidence of physical plant issues on the playground.

This self reported incident was reported to CCLD as required per regulations. Based on available information, there is not a preponderance of evidence to suggest that the incident occurred due to any violation of regulations. This report was read and reviewed with the center director, Dawn O'Malley. Notice of site visit shall be posted for 30 days.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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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