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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010192
Report Date: 11/12/2024
Date Signed: 11/12/2024 01:10:46 PM

Document Has Been Signed on 11/12/2024 01:10 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 RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:YWCA 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: 24CENSUS: 15DATE:
11/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:14 AM
MET WITH:Paloma Escalante De BurrowTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
NARRATIVE
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An unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Mindy Mohr in response to a self - reported incident involving child (C1) that occurred at the facility on 10/31/2024. During today's visit, LPA met with the Site Supervisor, Paloma Escalante De Burrow to discuss this incident. It was reported by the site supervisor that C1 was taken into the restroom by S2 to have their diaper changed. While C1 was in the restroom with S2, C1 was heard by 3 staff yelling and screaming "don't touch me" "stop" and "you are hurting me". The 3 staff who heard C1 were inside the classroom with music playing. The restroom is located outside next to the classroom. The door to the classroom was closed, while the door to the restroom was open. S1 stated when staff heard C1 yelling and screaming she immediately went into the restroom to help S2 with C1. When S1 walked into the restroom C1 was panicked, upset and crying. S1 stated she observed S2 holding C1 down over their knee, while trying to wipe C1. S1 told S2 she will take over, to which S2 replied with “no, I got this” and would not allow S1 to take over with changing C1. S1 stated she did take over and asked S2 to return to the classroom. S1 was able to calm C1 down and finished cleaning C1, and they both returned to the classroom.

C1 stated that they yelled at S2 because S2 was hurting them. C1 further stated that they asked S2 to stop but they wouldn’t, S2 just kept wiping and wiping, and it was burning. C1 also stated that S1 helped them to feel better. Furthermore, it was reported by both S1 and S3 that they have observed S2 speaking in an aggressive manner towards children while S3 specifically stated S2 loses their patience quickly with the children.

This incident was reported to Community Care Licensing as required per regulation. The site supervisor reported that S2 no longer works at the facility, and the last day S2 was at the facility was on 10/31/2024.

(Continued on LIC809-C)

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: YWCA PRESCHOOL-FORESTVILLE
FACILITY NUMBER: 493010192
VISIT DATE: 11/12/2024
NARRATIVE
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LPA Mohr informed Site Supervisor, Paloma Escalante De Burrow that this report dated 11/12/2024 documents one Type A citation. Type A citations shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

LPA Mohr informed Site Supervisor to provide a copy of this licensing report dated 11/12/2024 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

Exit interview conducted and report was reviewed with Site Supervisor, Paloma Escalante De Burrow.

A notice of site visit was given to facility representative and must remain posted for 30 days

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Melinda Mohr
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2024 01:10 PM - It Cannot Be Edited


Created By: Melinda Mohr On 11/12/2024 at 12:31 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-FORESTVILLE
FACILITY NUMBER: 493010192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2024
Section Cited
CCR
101223(a)(3)

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(a)The licensee shall ensure that each child is accorded the following personal rights:
(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Site Supervisor stated S2 no longer works at the facility, their last day at the facility was 10/31/2024. S1 knows the importance of this incident and that it has never been an issue and cannot happen in. S1 stated her first job is to keep the children safe.
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This requirement was not met as evidenced by: based on an Unusual Incident Report (UIR) submitted by the facility on 11/01/24, It was reported by the site supervisor that S2 took C1 into the restroom and caused the child to yell, scream and ask S2 to stop hurting them. This posed an immediate health and safety risk to 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:Melinda Mohr
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2024


LIC809 (FAS) - (06/04)
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