Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493006543
Report Date: 01/30/2017
Date Signed: 02/01/2017 03:51:30 PM

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:NORTH BAY CHILDREN'S CENTER - SCHOOL-AGEFACILITY NUMBER:
493006543
ADMINISTRATOR:BULLARD, MARLENEFACILITY TYPE:
840
ADDRESS:1001 A CHERRY STREETTELEPHONE:
(707) 763-6222
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:45CENSUS: 0DATE:
01/30/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Marisa Scheinberg, Site SupervisorTIME COMPLETED:
02:00 PM
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A Case Management visit was conducted at the facility by LPA N.Cunningham in response to an Unusual Incident Report received December 28, 2016. LPA met with Site Supervisor Marisa Scheinberg. According to the incident report and interviews conducted, at approximately 4:55pm on December 21, 2016, a 6 year old child walked towards the parking lot with a friend and friends mother. The parent turned the child around in front of the school bathrooms and water fountain. Interviews support children are usually in another area closer to the classroom. Children do have access to the play area by the bathrooms and water fountain. The Site Supervisor has reminded staff and children to stay in a designated area closer to the classroom. The Site Supervisor is also ordering walkie talkies so all staff can quickly communicate. Based on available information, it has been determined that the child did not leave the playground and was supervised when the incident occurred on December 21, 2016.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Nicolette CunninghamTELEPHONE: 707-588-5058
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2017
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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