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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045407980
Report Date: 04/04/2024
Date Signed: 04/04/2024 02:40:15 PM

Document Has Been Signed on 04/04/2024 02:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:CREATIVE SCHOLARS ACADEMY PRESCHOOLFACILITY NUMBER:
045407980
ADMINISTRATOR/
DIRECTOR:		RAY, NICOLEFACILITY TYPE:
850
ADDRESS:120 YELLOWSTONE DR.TELEPHONE:
(530) 809-2468
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY: 58TOTAL ENROLLED CHILDREN: 58CENSUS: 31DATE:
04/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Nikki RayTIME VISIT/
INSPECTION COMPLETED:
02:49 PM
NARRATIVE
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An unannounced case management inspection was conducted today at 11:17am by Licensing Program Analyst (LPA), Bianca Mendez. LPA met with licensee Nikki Ray. In response to an Unusual Incident Report that occurred on March 27th, child (C1) was sitting on the toilet and fell off the toilet and hit their left side forehead which sustained a red bump on their left side of their forehead and child was seen by the doctor for medical attention.

The licensee was interviewed on 4/4/24 at 11:17am and stated that they were informed of the incident regarding (C1) from staff but it did not occur to report the incident to Community Care Licensing. Licensee stated that the child was taken to the doctor to be checked for a concussion and came back to the facility with a doctor's note that they were clear to return to the facility. LPA interviewed 2 staff (S1-S2) who witnessed the incident with C1 that occurred on March 27th, 2024 between 11:30am-11:45am.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Bianca Mendez
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: CREATIVE SCHOLARS ACADEMY PRESCHOOL
FACILITY NUMBER: 045407980
VISIT DATE: 04/04/2024
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S1 and S2 stated they were both in the bathroom at the same time supervising children before their nap time. S1 stated that C1 had leaned forward and fell off the toilet hitting their head on the toilet next to them. S1 stated they wrote the incident report on the Procare App because they had witnessed C1 fall and had spoken to C1's parent during pick to inform them of the incident.. S2 they stated they wrote a incident report on March 27th at 12:07pm and the report was made on the Procare app. C1's parent was called immediately because C1 was crying and advised C1's parent to take them to the doctor to have them checked.

During today’s inspection, the facility was toured 1 child's record was reviewed. LPA observed 31 children in care.

Based on record review and staff interviews. Facility did not not report the unusual incident in a timely manner to CCLD within the 7 day The following deficiency(ies) is being cited on the LIC809-D.

Exit interview conducted and report was reviewed with the licensee Nikki Ray. Appeal Rights were provided.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Bianca Mendez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2024 02:40 PM - It Cannot Be Edited


Created By: Bianca Mendez On 04/04/2024 at 11:54 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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: CREATIVE SCHOLARS ACADEMY PRESCHOOL
FACILITY NUMBER: 045407980

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
CCR
101212(d)(1)(b)

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(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
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Facility with submit a Unusual Incident Report (UIR) to CCLD and will go over reporting requirements with staff. Licensee will submit a document verifying that staff have been trained to report unusual incidents to CCLD. Licensee will submit documentation by 4/14/24 ro CCLD.
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(1) Events reported shall include the following:(B) Any injury to any child that requires medical treatment.

Based on record review and staff interviews: facility did not report to CCLD a unusual incident regarding C1 receiving medical attention for a injury.
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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:Megan Aviles
LICENSING EVALUATOR NAME:Bianca Mendez
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


LIC809 (FAS) - (06/04)
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