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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 573619923
Report Date: 05/03/2024
Date Signed: 05/03/2024 10:38:36 AM

Document Has Been Signed on 05/03/2024 10:38 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
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: 46DATE:
05/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Director, Gabriela CortezTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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On May 3, 2024, Licensing Program Analyst (LPA) Lauren Scott Director, Gabriela Cortez for the purpose of a case management inspection due to deficiencies.

LPA Lauren Scott received a complaint on April 30, 2024 regarding an incident that occurred regarding children being left without supervision. Through interviews, it was revealed children were left without supervision on two additional occasions, including February 9, 2024 and June 23, 2023. Upon investigation, LPA Scott did not receive an Unusual Incident Report regarding any of the incidents. All unusual incidents, including absence of supervision, need to be reported to CCLD within 24 hours and a LIC 624 needs to be submitted within 7 days of the occurrence.

Based on the information obtained, it was determined that the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following Title 22 Deficiency is being cited on the subsequent 9099-D page.

Upon receipt of Type A citations, the Director shall post and provide copies of the LIC 9099-D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Director must also keep the signed LIC 9224, acknowledging receipt of LIC 9099-D in each child's file.

An exit interview conducted, and report was reviewed with the Director, Gabriela Cortez. Appeal 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: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 05/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2024
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 05/03/2024 10:38 AM - It Cannot Be Edited


Created By: Lauren Scott On 05/03/2024 at 09:42 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEREGRINE SCHOOL
FACILITY NUMBER: 573619923

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2024
Section Cited
CCR
101212(d)(c)

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101212(d)(c) Upon the occurrence... a report shall be made...within the Department's next working day...written report containing the information....shall be submitted...within seven days following the occurrence of such event. This requirement was not met as evidenced by:
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LPA provided copies of LIC624 for facility to use. Facility will send reports for incidents on 4/26/24, 2/9/24 and 6/23/23.
Director stated they will call the officer of the day or LPA with any questions regarding if an incident needs to be reported or not
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Facility did not inform CCLD of the unusual incident that occurrent, within 24 hours, nor did she submit a LIC624 within 7 days. This is a potential health and sfety 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:Chayntel Hunter
LICENSING EVALUATOR NAME:Lauren Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2024


LIC809 (FAS) - (06/04)
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