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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 574500035
Report Date: 03/07/2024
Date Signed: 03/07/2024 09:36:28 AM

Document Has Been Signed on 03/07/2024 09:36 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:GIBSON STATE PRESCHOOLFACILITY NUMBER:
574500035
ADMINISTRATOR:GABRIELA GARCIAFACILITY TYPE:
850
ADDRESS:312 GIBSON RDTELEPHONE:
(530) 406-5951
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 21DATE:
03/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Child Development Coordinator, Maria Lewis TIME COMPLETED:
09:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Lauren Scott and Investigator, Nathan Gonzalez conducted a case management inspection at the facility. LPAs met with Child Development Coordinator, Maria Lewis. At time of arrival LPA's observed 21 children and four staff.

Based on interviews with staff and parents, as well as review of facility documentation, the facility did not notify parents immediately of a an injury which was more serious than a minor cut or scratch which poses a potential health, safety or personal rights risk to persons in care.

Title 22 deficiencies have been cited on subsequent page, LIC 809D.

An exit interview was conducted, and a Plan of Correction was reviewed and developed with the Child Development Coordinator, Maria Lewis. A copy of this report and appeal rights were discussed and left for Director. 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: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/07/2024
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 03/07/2024 09:36 AM - It Cannot Be Edited


Created By: Lauren Scott On 03/07/2024 at 09:08 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: GIBSON STATE PRESCHOOL
FACILITY NUMBER: 574500035

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2024
Section Cited
CCR
101226(a)

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(a) The licensee shall immediately notify the child's authorized representative if the child becomes ill or sustains an injury more serious than a minor cut or scratch….
This requirement was not met as evidenced by:
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Facility will conduct a training on reporting requirements, including injuries that are considered more serious that a minor cut or scratch. Director will submit training notes with staff signatures to LPA
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Based on interviews and facility documentation, it was revealed that the facility did not contact parents when the child’s injury became more serious.
This is an immediate health and safety 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: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024


LIC809 (FAS) - (06/04)
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