493006901-2-19-2026-01-CC-MMOR-DRKS7E-20260223123726

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 493006901
Report Date: 02/19/2026
Date Signed: 02/19/2026 09:51:47 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/26/2025 and conducted by Evaluator Sebastian Phouthavong

PUBLIC

COMPLAINT CONTROL NUMBER: 01-CC-20251126130444

FACILITY NAME:	4CS WILLOW CREEK STATE PRESCHOOL		FACILITY NUMBER:	493006901
ADMINISTRATOR:	PATINO, OFELIA		FACILITY TYPE:	850
ADDRESS:	2536 MARLOW ROAD		TELEPHONE:	(707) 570-2607
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	32	CENSUS: 13	DATE:	02/19/2026
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Ofelia Patino		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Lack of supervision resulting in child sustaining a fracture

INVESTIGATION FINDINGS:

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A subsequent complaint investigation visit was conducted today by Licensing Program Analyst (LPA), Sebastian Phouthavong who met with Site Supervisor, Ofelia Patino (SS) for the purpose of delivering complaint investigation finding for the above allegation. LPA, previously conducted an inspection on 12/04/2025 to initiate the investigation and met with Site Supervisor (SS) to discuss the allegation, conduct interview(s), make observations, and request documents. LPA also conducted additional inspections to the facility on 12/16/2025 and 02/10/2026. It is alleged that due to a Lack of supervision resulted in child sustaining a fracture, specifically that staff did not observe when Child 1 (C1) fell from a play structure resulting in an injury.

During the course of the investigation, LPA conducted interviews with Site Supervisor (SS), six staff (S1 – S6), three children (C2 – C4) and three parents (P1 – P3) from 12/04/2025 to 02/10/2026. SS stated that the incident occurred during staff break transitions. SS further stated that S1 was positioned in the middle of the outdoor area with the children, while SS was standing near the entrance.
(Continued on LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Melinda Mohr
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 01-CC-20251126130444

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 4CS WILLOW CREEK STATE PRESCHOOL	FACILITY NUMBER: 493006901
	VISIT DATE: 02/19/2026

NARRATIVE

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(Continued from LIC9099)
SS admitted that they did not observe C1’s fall, but SS and S1 immediately assisted C1 after the incident occurred. S1 stated that they were outside at the time of C1’s fall, however, S1 also admitted that they did not observe the incident and immediately went to assist C1 after the fall, collaborating with SS’s statement.

According to evidence received by the department, it was confirmed that C1 sustained a fracture as a result of the fall at the facility.

Based on the information gathered during this investigation, the preponderance of the evidence standard has been met. Therefore, the allegation is determined to be substantiated. California Code of Regulations, Title 22, is being cited on the attached LIC 9099-D. Appeal rights were provided. An exit interview was conducted, and this report was read and discussed with Site Supervisor, Ofelia Patino (SS). The Notice of Site Visit shall be posted for 30 days.

SUPERVISORS NAME: Melinda Mohr
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 01-CC-20251126130444

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 4CS WILLOW CREEK STATE PRESCHOOL	FACILITY NUMBER: 493006901
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/19/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/12/2026 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	101229 (a)(1) The licensee shall provide care and supervision as necessary to meet the children’s needs. No child(ren) shall be left without the supervision of a teacher at any time.... Supervision shall include visual observation. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Site Supervisor was provided 101229 Responsibility for Providing Care and Supervision. Site Supervisor stated they will update the facility supervision policy when supervising children outdoor including visual observation. The updated supervision policy will be submitted to LPA by March 12, 2026.
	8 9 10 11 12 13 14	Based on interviews and evidences, staff did not observe when one child (C1) fell from a play structure resulting in an injury. This poses a potential health, safety and/or personal rights risk to the children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Melinda Mohr
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2026

LIC9099 (FAS) - (06/04)

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