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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010190
Report Date: 11/01/2024
Date Signed: 11/01/2024 02:37:18 PM

Document Has Been Signed on 11/01/2024 02:37 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:YWCA PRESCHOOL-SEBASTOPOLFACILITY NUMBER:
493010190
ADMINISTRATOR/
DIRECTOR:		RIVAS NINO, NATHALIEFACILITY TYPE:
850
ADDRESS:466 JOHNSON STREETTELEPHONE:
(707) 829-2160
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 22TOTAL ENROLLED CHILDREN: 22CENSUS: 10DATE:
11/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:41 PM
MET WITH:Nathalie Rivas NinoTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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A subsequent unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Selena Mariani in response to a self-reported, lack of supervision incident involving child C1 and the Site Supervisor (SS) Nathalie Rivas Nino that occurred on 10/16/24. During today’s visit, the LPA met with SS to discuss the incident.

On 10/17/24, it was reported via written unusual incident report (UIR) by SS that on 10/16/24 at approximately 3:51pm, SS was with seven preschool-age children in the classroom. On 10/28/24 LPA Selena conducted interviews with Director (D1) and Parent (P1). LPA interviewed SS, on 11/1/24, who stated that on 10/16/24, she heard the door alarm. The door was left open by the door stopper. SS went to close the door and see if a parent was outside and that’s when SS saw C1 had ran out the door to the fenced in play yard. C1 was outside unsupervised for less than a minute. SS did a head count to ensure no other children went outside. SS informed C1's parent at pick up and submitted an UIR to the Department. SS stated that an additional mirror was installed in the classroom and is in process in getting a different door alarm.

Based on interviews conducted by the LPA with Director (D1) and Parent (P1) on 10/28/24 and SS on 11/01/24, both staff members and parent interviewed stated that they corroborate the narrative of events described in the UIR written and submitted by SS.

Based on available information, it has been determined that adequate supervision was not provided to child C1 during the incident on 10/16/2024. The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D. This report was read and reviewed with the Site Supervisor, Nathalie Rivas Nino. Notice of site visit shall be posted for 30 days. Appeal rights provided. Due to technical issues, report will be emailed to Site Supervisor by 11/2/24.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Selena Mariani
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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Document Has Been Signed on 11/01/2024 02:37 PM - It Cannot Be Edited


Created By: Selena Mariani On 11/01/2024 at 01:03 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: YWCA PRESCHOOL-SEBASTOPOL
FACILITY NUMBER: 493010190

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
101229(a)(1)

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Care and Supervision. No child(ren) shall be left without the supervision of a teacher at any time, except as specified in Sections
101216.2(e)(1) and 101230(c)(1). Supervision
shall include visual observation.
This requirement was not met as evidenced by:
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The site supervisor stated that the center will be conducting a training for all staff in order to provide additional training to staff on
active supervision The site supervisor stated that she will email a summary of the training along with proof of attendance to the
LPA Selena at selena.mariani@dss.ca.gov by 10/22/24.
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Based on interviews conducted by the LPA with
D1 and P1 on 10/28/24 and SS on 11/01/24, it was
corroborated that on 10/16/24 at approximately
3:51pm, child C1 was without supervision of a teacher for approximately under one minute when C1 ran out of the classroom to the fenced in play yard before being reunited with their class by SS. This presents a potential threat to the health and safety of children in care.
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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.
SUPERVISOR'S NAME:Leslie Lepori
LICENSING EVALUATOR NAME:Selena Mariani
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2024


LIC809 (FAS) - (06/04)
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