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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493006901
Report Date: 05/03/2024
Date Signed: 05/03/2024 11:42:50 AM

Document Has Been Signed on 05/03/2024 11:42 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:4CS WILLOW CREEK STATE PRESCHOOLFACILITY NUMBER:
493006901
ADMINISTRATOR/
DIRECTOR:		SCHAEFER, PAULAFACILITY TYPE:
850
ADDRESS:2536 MARLOW ROADTELEPHONE:
(707) 570-2607
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 32TOTAL ENROLLED CHILDREN: 32CENSUS: 26DATE:
05/03/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Paula SchaeferTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Glenn Ouye met with Site Supervisor, Paula Schaefer and staff S1 to discuss a self reported incident which occurred on 3/28/24 where child (C1) claims to have fallen off a tricycle.

Site Supervisor said that children were using the tricycle's between 9am to 10am when the children first go outside in the morning. The children then go back inside for circle time. She said that all of their teachers were positioned in supervisory locations to ensure line of sight supervision. The teachers said that none of the children fell from the tricycles that morning. Child C1 was playing inside and outside during the day. C1 did not complaint about not feeling well, nor did he show any signs of not feeling well. C1 did not have any bumps, marks, cuts or scrapes on his head indicating that C1's head hit anything. In the afternoon at approximately 3pm C1 was outside and two teachers noticed he was sitting down and seemed tired which seemed unusual for C1. C1 told the teachers that he was fine but wanted to go home. Site Supervisor said that it was about the time that C1's mother usually picked him up. Shortly after, C1's mother did pick him up. The Site Supervisor said that C1's parents took C1 to the hospital because the child was complaining about a headache. Parent said that C1 was not making sense when talking to the parent. C1 was diagnosed with a probable concussion. Parent's took child back to hospital for a second time later in the evening and a CT scan was done. The CT scan did show that C1 had a concussion.

The teachers were in a supervisory location while children were playing outside and indoors, child C1 was not observed to be injured and did not indicate that he was injured at the facility while speaking with staff . The onset of symptoms and the child not showing any head marks, bumps or bruises makes difficult to determine that an injury occurred and the time of injury.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: 4CS WILLOW CREEK STATE PRESCHOOL
FACILITY NUMBER: 493006901
VISIT DATE: 05/03/2024
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Site Supervisor spoke with parent the following day and child was feeling better with a slight headache.

The Site Supervisor held a training on 4/3/24 which covered child supervision to prevent unknown accidents from occurring in the future.

Based on interview of the Site Supervisor and staff there is no indication of a violation of regulation.

No deficiency will be cited at this time.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Glenn Ouye
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024
LIC809 (FAS) - (06/04)
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