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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573619923
Report Date: 05/16/2024
Date Signed: 05/16/2024 02:50:15 PM

Document Has Been Signed on 05/16/2024 02:50 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 SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:PEREGRINE SCHOOLFACILITY NUMBER:
573619923
ADMINISTRATOR/
DIRECTOR:		GABRIELA CORTEZFACILITY TYPE:
850
ADDRESS:2650 LILLARD DRIVETELEPHONE:
(530) 753-5500
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 90TOTAL ENROLLED CHILDREN: 90CENSUS: 68DATE:
05/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:director, Gabriela CortezTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On May 16, 2024, Licensing Program Analyst (LPA) Lauren Scott met with Director, Gabriela Cortez for the purpose of an unannounced Case Management inspection.

On May 15, 2024, facility contacted CCLD regarding an Unusual Incident Report (UIR) that stated that one napping child was left in the classroom alone while the one supervising staff stepped outside the classroom. LPA conducted interviews with staff and obtained information pertinent to the allegation.

The facility reported the UIR to Community Care Licensing within 24hrs and submitted a written UIR within 7 days.

Based on the interviews and information obtained, one Title 22 Deficiency has been issued on the attached LIC 809-D. The facility was informed that this report dated 5/16/2024 documents one Type A citation which shall be posted for 30 consecutive days. The facility shall also provide a copy of this licensing report 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. Facility has been provided with appeal rights.

Exit interview conducted and report was reviewed with director, Gabriela Cortez. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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 05/16/2024 02:50 PM - It Cannot Be Edited


Created By: Lauren Scott On 05/16/2024 at 01:00 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: 573619923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2024
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 will conduct a staff training regarding staff communication between classrooms, in order to maintain supervision. Training will discuss use of walkies and back up protocols.
Director will submit signed meeting notes by POC date
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Based on interviews, the facility did not comply with the section cited above where one child was was left inside the classroom alone without staff 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:Chayntel Hunter
LICENSING EVALUATOR NAME:Lauren Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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