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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573614564
Report Date: 07/19/2023
Date Signed: 07/19/2023 01:11:51 PM

Document Has Been Signed on 07/19/2023 01:11 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:PEREGRINE SCHOOLFACILITY NUMBER:
573614564
ADMINISTRATOR:VIDRIO, FABIOLAFACILITY TYPE:
850
ADDRESS:2907 PORTAGE BAY WESTTELEPHONE:
(530) 758-8845
CITY:DAVISSTATE: CAZIP CODE:
95616
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 38DATE:
07/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Fabiola VidrioTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Jennie Tedlos and Lauren Scott met with Director, Fabiola Vidrio to follow up on an Unusual Incident Report (UIR) submitted to Community Care Licensing on 07/07/2023. During today's visit the facility was toured. Present were 38 children in care and 14 staff.

LPAs interviewed the Director Fabiola and Director Heidi as well as 3 staff who were present the day of the incident. LPAs reviewed and discussed this report with the Director.

The facility reported the UIR to Community Care Licensing within 24hrs. A written UIR was submitted within 7 days, describing the specifics of the incident.

A Type A violation was assessed on a subsequent 809-D page. An exit interview was conducted, and the report was reviewed with Director. 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: Bettina Engelman
LICENSING EVALUATOR NAME: Jennie Tedlos
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2023
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 07/19/2023 01:11 PM - It Cannot Be Edited


Created By: Jennie Tedlos On 07/19/2023 at 12:41 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: PEREGRINE SCHOOL
FACILITY NUMBER: 573614564

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/20/2023
Section Cited
CCR
101170(f)(1)

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(f) A licensee.... may request a transfer of a criminal record clearance from one state licensed facility to another....by providing the following documents to the Department:
(1) A signed Criminal Background Clearance Transfer Request, LIC 9182.This requirement was not met as evidenced by:
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Facility will complete LIC9182 and have the two staff members transferred to the facility. Director will submit proof of transfer to LPA.
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Based on record review, LPAs were unable to locate LIC 9182 for two (2) staff members who were not associated to the facility which poses an immediate 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:Bettina Engelman
LICENSING EVALUATOR NAME:Jennie Tedlos
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2023


LIC809 (FAS) - (06/04)
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