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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 574500485
Report Date: 03/25/2024
Date Signed: 03/25/2024 09:48:54 AM

Document Has Been Signed on 03/25/2024 09:48 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:YCOE MARGUERITE MONTGOMERYFACILITY NUMBER:
574500485
ADMINISTRATOR:GENET TELAHUN/SILVIA MEZAFACILITY TYPE:
850
ADDRESS:1441 DANBURY STREETTELEPHONE:
(530) 668-3010
CITY:DAVISSTATE: CAZIP CODE:
95618
CAPACITY: 48TOTAL ENROLLED CHILDREN: 48CENSUS: 8DATE:
03/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Site Coordinator, TIME COMPLETED:
10:00 AM
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On March 25, 2024, Licensing Program Analysts (LPAs) Lauren Scott and Janie Davis met with Site Coordinator, Connie Luna Garcia for the purpose of an unannounced Case Management inspection. LPA observed 8 children supervised by 4 staff.

At time of inspection, LPA toured the temporary play yard that was installed and inspected on 12/13/23. Facility will use this space while pour and play is being installed in the play yard. Facility will notify CCLD once it is complete and the temporary play yard is no longer needed.

LPA also followed up on an Unusual Incident Report (UIR) that was reported to CCLD on March 15, 2024. Facility contacted CCLD stating that the children of room E3 were taken to the restroom. When the staff returned, they counted the children and realized one was missing. One staff opened the door to look for the child, and saw the child with a preschool teacher from room E4. LPA conducted interviews with staff that was present during the incident and learned the child was left in the bathroom for approximately 2 minutes.

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 3/25/2024 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 Site Coordinator, Connie Luna Garcia. 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: 03/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2024
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 03/25/2024 09:48 AM - It Cannot Be Edited


Created By: Lauren Scott On 03/25/2024 at 09:28 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: YCOE MARGUERITE MONTGOMERY
FACILITY NUMBER: 574500485

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/26/2024
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 stated they held a staff meeting to discuss supervision plan. Facility also discussed procedures for going to and from places, including bathroom and outside. Facility will submit signed meeting notes to LPA via email by POC date.
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Based on interviews, the facility did not comply with the section cited above 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: 03/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2024


LIC809 (FAS) - (06/04)
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