Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490109272
Report Date: 09/12/2018
Date Signed: 09/20/2018 11:09:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:4CS PETALUMA CHILD DEVELOPMENT CENTERFACILITY NUMBER:
490109272
ADMINISTRATOR:DUSEK, LINDAFACILITY TYPE:
850
ADDRESS:401 S MC DOWELLTELEPHONE:
(707) 763-4990
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:54CENSUS: 14DATE:
09/12/2018
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maria Vencez, Lead TeacherTIME COMPLETED:
02:00 PM
NARRATIVE
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A Case Management visit was conducted at the facility by Licensing Program Analyst (LPA) N.Cunningham in response to an Unusual Incident Report that was called in on September 6, 2018 involving a lack of supervision. LPA met with Lead Teacher and discussed the incident. According to interviews conducted, at approximately 12:10pm on September 5, 2018, Child 1 (See 811 - Confidential Names) who is 4 1/2 years old, climbed over the play yard fence which borders another preschool campus. Child 1 climbed down the fence and ended in the neighboring preschool play yard. Interview with Staff 1 and Staff 2 support that Staff 1 observed Child 1 climb up the South West fence and climb over into another play yard. Staff 2 stated they arrived at their assigned area on the play yard, noticed Child 1 on the fence, ran over to the fence, spoke to the child, climbed over the fence and joined Child 1 at the sand box. Staff 2 reported that Child 1 was out of the play yard for approximately 1 minute. It was reported that the Child 1 was unsupervised for 1 second. During today’s visit there were 14 children accounted for and being supervised by five staff members. Based on available information, it has been determined that preschool staff were not properly supervising the children when the incident occurred on September 5, 2018. This report was reviewed and discussed with the Lead Teacher at 1:30pm.
Notice of Site Visit shall be posted for 30 days from today's visit.

The following violation of the California Code of Regulations, Title 22; Division 12, was cited: see LIC 809D. Appeal Rights were provided.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Nicolette CunninghamTELEPHONE: 707-599-1479
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2018
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: 4CS PETALUMA CHILD DEVELOPMENT CENTER
FACILITY NUMBER: 490109272
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2018
Section Cited
CCR
101229(a)(1)
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Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).
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Staff held a meeting with the children and discussed how important it is to stay on their side of the fence. Facility Manager visited the site to determine what could be changed to make the fence so children are unable to climb it. Program Director will send a detailed plan on how the fence will be modified. On going
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This requirement is not met as evidence by: On 9/5/2018, at approximately 12:10pm, Child 1 climbed the South West fence which borders another preschool play ground. Staff 2 and Child 1 were out of the facility play yard for approximately 1 minute.
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training will be conducted to remind staff to make sure that they are in their assigned areas and to make sure to communicate with all staff when they need to move from their assigned area to ensure that adequate supervision is provided at all times.
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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: Alexis HollonTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Nicolette CunninghamTELEPHONE: 707-599-1479
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2018
LIC809 (FAS) - (06/04)
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