Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493006543
Report Date: 10/14/2019
Date Signed: 10/14/2019 04:27:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:NORTH BAY CHILDREN'S CENTER - SCHOOL-AGEFACILITY NUMBER:
493006543
ADMINISTRATOR:MARISA SCHEINBERGFACILITY TYPE:
840
ADDRESS:1001 CHERRY STREETTELEPHONE:
(707) 763-6222
CITY:PETALUMASTATE: CAZIP CODE:
94952
CAPACITY:30CENSUS: 10DATE:
10/14/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Kerstin BandnerTIME COMPLETED:
04:40 PM
NARRATIVE
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A case management visit was made the the facility by Licensing Program Analyst (LPA) J. Velasco in response to an Unusual Incident/Injury Report (UIR) received by the Department on September 12, 2019. Site Supervisor (D1) reported that at 1:30 p.m. on September 11, 2019, a child (C1) was playing on the playground with other children while supervised by a staff (S1). Facility was not out of ratio. S1 hit C1 on the arm, and C1 sustained two scratches on the arm. S1 was dismissed. D1 stated they will not allow S1 to work at this facility again. C1's parent was notified. C1 did not receive medical attention. D1 consulted with the NBCC regional manager (M1) and assistant regional manager (M2). M1 filed the UIR and cross reported to CCLD, law enforcement, and CPS as directed by the Department. M1 and D1 notified all parents of the incident and held a parent meeting to discuss the incident and the facility's plan for preventing future recurrence. LPA was provided with all documentation. During today's visit, LPA observed two staff members supervising 10 children. LPA toured the facility, obtained facility documents, and conducted interviews with D1 and M1.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809-D. Appeal Rights were provided.

Reports citing Type A violations are to be provided to parents/guardians of children currently enrolled and to parents/guardians of children newly enrolled at the facility during the next 12 months. Parents/guardians must sign Form LIC 9224 to be kept in each child's file.



Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISOR'S NAME: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2019
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,
, CA

FACILITY NAME: NORTH BAY CHILDREN'S CENTER - SCHOOL-AGE
FACILITY NUMBER: 493006543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2019
Section Cited

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Personal Rights-The licensee shall ensure that each child is accorded the following personal rights,To be accorded safe, healthful and comfortable accommodations...to meet his/her needs. This requirement has not been met as evidenced by
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LPA's review of facility documents and statements by facility supervisor (D1) and regional manger (M1) that a staff (S1) did hit a child (C1). This posed 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: Alexis HollonTELEPHONE: (707) 588-5036
LICENSING EVALUATOR NAME: Jennifer VelascoTELEPHONE: (707) 588-5044
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2019
LIC809 (FAS) - (06/04)
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