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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570310219
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:19:49 PM

Document Has Been Signed on 05/31/2024 02:19 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:DAVIS PARENT NURSERY SCHOOL #2FACILITY NUMBER:
570310219
ADMINISTRATOR/
DIRECTOR:		BECKY MONTGOMERYFACILITY TYPE:
850
ADDRESS:426 WEST EIGHTH STREETTELEPHONE:
(530) 757-5377
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 36TOTAL ENROLLED CHILDREN: 36CENSUS: 25DATE:
05/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Becky MontgomeryTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 5/31/2024, Licensing Program Analyst (LPA) Jennie Tedlos, met with Director Becky Montgomery for the purpose to conduct an unannounced case management inspection due to deficiencies. LPA observed 25 children supervised by staff.

Upon conducting a complaint investigation, it was revealed through interview that an incident occurred on 5/14/24 regarding Child 1 and Child 2 going to the bathroom unsupervised, leading to inappropriate touching. This incident was not reported to the Community Care Licensing Department.

LPA Tedlos informed Director Montgomery that this report dated 05/31/2024, documents one Type B citation, regarding reporting requirements, stating there is a potential risk to the health, safety, or personal rights of children in care.

An exit interview conducted, and report was reviewed with the Director, Montgomery. Appeal of Rights were provided. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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 05/31/2024 02:19 PM - It Cannot Be Edited


Created By: Jennie Tedlos On 05/31/2024 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DAVIS PARENT NURSERY SCHOOL #2
FACILITY NUMBER: 570310219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2024
Section Cited
CCR
101212(d)

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101212 Reporting Requirements (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department ...within the Department's next working day... a written report containing the information shall be...
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Director shall submit an Unusual Incident Report to LPA about the incident that took place on 5/14/24. Director will watch the CCLD training video on Reporting Requirements and write and send a statement to LPA acknowleging their understanding on what incidents to report to CCLD.
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submitted... within 7 days...
This requirement was not met as evidenced by: LPA learned that Child1 and Child 2 were left sunsupervised in the bathroom on 5/14/24 & was not reported to CCLD. This poses an potential health & 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:Karyn Guerra
LICENSING EVALUATOR NAME:Jennie Tedlos
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
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