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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570312670
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:57:33 AM

Document Has Been Signed on 01/26/2023 11:57 AM - 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:CATALYST KIDS - ROBERT E. WILLETTFACILITY NUMBER:
570312670
ADMINISTRATOR:ANGELO, MARISSAFACILITY TYPE:
840
ADDRESS:1207 SYCAMORE LANETELEPHONE:
(530) 758-8342
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 70TOTAL ENROLLED CHILDREN: 70CENSUS: 8DATE:
01/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Savanah CovarrubiasTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Salene Mayberry met with Program Lead Savanah Covarrubias to follow up on the Unusual Incident Report (UIR) submitted to Community Care Licensing on January 17, 2023. During today's visit the facility was toured.

LPA interviewed Program Lead who was present during the incident.

LPA learned that on 1/10/23, during the afternoon transition back inside, Child #1 (C1) was left behind without visual supervision while the other children and staff returned to the classroom. Approximately 5 minutes later staff realized C1 was missing and located him approximately 64 feet away from the front door.

A Type A deficiency was cited on the subsequent page (LIC809-D) of this report. Upon receipt of Type A citations, the facility shall post and provide copies of the LIC809-D for parents/guardians of children currently in care and for parents/guardians of newly enrolled children for the next 12 months. The facility must also keep a signed “Acknowledging Receipt of Licensing Reports” (LIC9224) in each child's file.

The report was reviewed with Program Lead. LPA provided Program Lead with a copy of the report and Appeal Rights. A Notice of Site Visit was posted, and Program Lead understands it must remain posted for 30 days, and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Salene Mayberry
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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 01/26/2023 11:57 AM - It Cannot Be Edited


Created By: Salene Mayberry On 01/26/2023 at 11:33 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: CATALYST KIDS - ROBERT E. WILLETT
FACILITY NUMBER: 570312670

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited
CCR
101229(a)(1)

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101229(a)(1) No child(ren) shall be left without...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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Program Lead (PL) advised that they have created a new name to face document that staff will now use each day to track all counts for transitions. PL provided a copy to LPA. PL also advised that they had a staff meeting on 1/17/23, where they discussed the importance of visual supervision and
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Licensing learned that Child#1 was left without visual supervision by staff for approximately 5 minutes on 1/10/2023. This poses an immediate risk to the health and safety of children in care.
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the implementation of the new document. PL provided LPA with a copy of the meeting attendance sheet and agenda.

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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:Bettina Engelman
LICENSING EVALUATOR NAME:Salene Mayberry
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023


LIC809 (FAS) - (06/04)
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