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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570312615
Report Date: 03/14/2024
Date Signed: 03/14/2024 03:16:44 PM

Document Has Been Signed on 03/14/2024 03:16 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:CATALYST KIDS - NORTH DAVISFACILITY NUMBER:
570312615
ADMINISTRATOR:EVILA FLORESFACILITY TYPE:
840
ADDRESS:607 EAST 14TH STREETTELEPHONE:
(530) 756-4350
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 112TOTAL ENROLLED CHILDREN: 112CENSUS: 7DATE:
03/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Michelle Vang SychaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jennie Tedlos met with Teacher Michelle Vang Sycha to follow up on the Unusual Incident Report (UIR) submitted to Community Care Licensing on 3/12/2023. During today's visit the facility was toured. Present were 5 children in care and 5 staff members were at the facility.

LPA toured the facility, observed the care and supervision of children, reviewed records, and conducted interviews with teachers and children.

On 3/12/24, the facility contacted CCLD regarding an Unusual Incident Report (UIR) that stated one child poked 2 other students in their palms with a tool that had a pen on one end and a small exacto knife on the other end. LPA conducted interviews with staff and learned the child found the tool elsewhere, not on the facility's premises, and brought it into class. Although the injuries were minor and the staff immediately provided First Aid, staff did not have visual supervision of the incident when it occurred. Resulting in a lack of supervision.

A Type A violation was assessed on a subsequent 809-D page. Upon receipt of Type A citations, facility shall post and provide copies of the LIC 809D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. Facility must also keep the signed LIC 9224, Acknowledging Receipt of Licensing Reports LIC 809D in each child's files.

An exit interview was conducted, and the report was reviewed with Teacher Michelle Vang Sycha. Licensee Appeal Rights were provided to facility. A Notice of Site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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 03/14/2024 03:16 PM - It Cannot Be Edited


Created By: Jennie Tedlos On 03/14/2024 at 01:17 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: CATALYST KIDS - NORTH DAVIS
FACILITY NUMBER: 570312615

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2024
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision... (1) No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation. This requirement was not met as evidenced by:
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Facility stated they are no longer allowing children to bring personal items to be used in class, children must use classroom supplies only. Facility will also conduct a staff meeting regarding "line of sight" and supervision in the classroom. Facility will send LPA signatures of staff in attendance.
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Based on interviews, the facility did not comply with the section cited above due to a lack of supervision which poses an immediate health, safety or personal rights risk to persons 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: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


LIC809 (FAS) - (06/04)
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