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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010192
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:38:19 PM

Document Has Been Signed on 04/25/2024 01:38 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:YWCA STARS PRESCHOOL-FORESTVILLEFACILITY NUMBER:
493010192
ADMINISTRATOR/
DIRECTOR:		PALOMA ESCALANTE DE BURROWFACILITY TYPE:
850
ADDRESS:6321 HWY 116TELEPHONE:
(707) 887-2279
CITY:FORESTVILLESTATE: CAZIP CODE:
95436
CAPACITY: 24TOTAL ENROLLED CHILDREN: 31CENSUS: 21DATE:
04/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Paloma Escalante de BurrowTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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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 that occurred at the facility on 04/12/24. During today’s visit, the LPA met with the site supervisor, Paloma Escalante de Burrow to discuss the incident. It was reported by the site supervisor that during afternoon snack time on 04/12/24 at 03:15pm, child C1, who has a peanut allergy, ingested peanut butter that was unintentionally served by staff S1. The site supervisor reported that both staff S1 and S2 observed C1 consume the peanut butter and observed C1 having difficulty breathing and breaking out in a rash. The site supervisor reported that after learning of this incident from S2, she contacted 911 while S2 notified C1’s authorized representative. The site supervisor reported that while waiting for emergency medical services to arrive on site, the 911 dispatcher instructed her to administer the child’s epinephrine injector, which was located on site. The site supervisor reported that C1 along with their authorized representative was transported to a local hospital by emergency medical services within five minutes of the epinephrine injector being administered. The site supervisor reported that C1 was treated at the hospital and released the same day.

This incident was reported to Community Care Licensing as required per regulations. The site supervisor reported that a change of policy was enacted because of this incident; the facility does not permit any peanut products in the classroom if there is a child with a peanut allergy enrolled.

California Code of Regulations, Title 22 is being cited on the attached LIC 809-D. An exit interview was conducted, and this report was read and discussed with the facility’s site supervisor, Paloma Escalante De Burrow. Appeal rights were provided. The Notice of Site Visit shall be posted for 30 days.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2024
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 04/25/2024 01:38 PM - It Cannot Be Edited


Created By: Yang Yang On 04/25/2024 at 11:56 AM
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 STARS PRESCHOOL-FORESTVILLE
FACILITY NUMBER: 493010192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/10/2024
Section Cited
CCR
101223(a)(2)

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The licensee shall ensure that each child is accorded the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

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The site supervisor stated that an all staff training will be conducted to discuss the facility's policies and procedures regrading food safety and allergies.
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This requirement was not met as evidenced by: based on an Unusual Incident Report (UIR) submitted by the facility on 04/16/24, It was reported by the site supervisor that during afternoon snack time on 04/12/24 at 03:15pm, child C1, who has a peanut allergy, ingested peanut butter that was unintentionally served by staff S1 and required medical attention. This posed a potential health and safety hazard to the child in care.
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The site supervisor will submit a copy of the meeting agenda and staff sign in sheet to the LPA by 05/10/24.

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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:Alexis Hollon
LICENSING EVALUATOR NAME:Yang Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2024


LIC809 (FAS) - (06/04)
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