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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125408329
Report Date: 05/28/2025
Date Signed: 05/28/2025 02:38:00 PM

Document Has Been Signed on 05/28/2025 02:38 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
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:CAL POLY HUMBOLDT CHILDREN'S CENTER RM#104,108,125FACILITY NUMBER:
125408329
ADMINISTRATOR/
DIRECTOR:		WILSON, ELIZABETH-ANNEFACILITY TYPE:
850
ADDRESS:1350 C STREETTELEPHONE:
(707) 826-3838
CITY:ARCATASTATE: CAZIP CODE:
95521
CAPACITY: 58TOTAL ENROLLED CHILDREN: 50CENSUS: 36DATE:
05/28/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Betsy WilsonTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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An unannounced case management inspection was conducted today 05/28/2025 at 1:00 p.m. by Licensing Program Analysts (LPA) Noah Wheeler and Kiriko Lynch. LPAs met with facility representative Betsy Wilson in response to an Unusual Incident Report self-reported by the facility on 05/01/2025, and received by the Department. Facility representative stated the classroom was transitioning from outside to inside for snack and staff miscounted during the transition. She stated a teacher (S2) was leaving her shift noticed one child (C1) was on the playground, and immediately notified classroom staff. She stated staff immediately went outside and found C1 retrieving a toy near the sandbox, and child was brought inside after approximately 5-10 minutes of being left unattended.

The facility representative was interviewed on 05/28/2025, and stated that on 05/01/2025 at approximately 1:00 p.m., one child (C1) were left outside during transition, and staff did not notice the child was missing for approximately 5-10 minutes. One additional staff (S1) were also interviewed on 05/28/2025 and stated C1 was left unattended for approximately 5-15 minutes from outside to inside transition into snack. Continued on 809-C
NAME OF LICENSING PROGRAM MANAGER: Erin Virrueta
NAME OF LICENSING PROGRAM ANALYST: Noah Wheeler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: CAL POLY HUMBOLDT CHILDREN'S CENTER RM#104,108,125
FACILITY NUMBER: 125408329
VISIT DATE: 05/28/2025
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During today’s inspection, the facility was toured and LPAs observed care and supervision to children provided by staff to children in care. LPAs observed outside playground is completely fenced with a latched gate.

Based on interviews and records review, LPA found staff failed to conduct accurate head counts for children when transitioning from outside to inside, and staff also failed to check the playground for children who may have been hiding. LPA found a staff (S1) left a child (C1) on the playground for a period of time approximately 5 to no more than 10 minutes. The following deficiency is being cited on the LIC809-D.

LPAs Noah Wheeler and Kiriko Lynch informed facility representative Betsy Wilson that this report dated 05/28/2025 documents one Type A citation, which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care. LPAs Noah Wheeler and Kiriko Lynch informed the facility representative to provide a copy of this licensing report dated 04/29/2025 that documents any Type A citation(s) 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 children's files for verification.



Exit interview conducted and report was reviewed with the facility representative Betsy Wilson. Notice of Site Visit posted. Appeal Rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Erin Virrueta
NAME OF LICENSING PROGRAM ANALYST: Noah Wheeler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/28/2025 02:38 PM - It Cannot Be Edited


Created By: Noah Wheeler On 05/28/2025 at 02:16 PM
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: CAL POLY HUMBOLDT CHILDREN'S CENTER RM#104,108,125
FACILITY NUMBER: 125408329

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2025
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the children's needs.
(1) No child(ren) shall be left without the supervision of a teacher at any time. except as specified in Sections 101216.2(e)(1)...
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Facility representative stated that facility had a staff meeting, and teacher's updated supervision policies and best practices written documentation was provided. POC cleared at time of visit.
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 and 101230(c)(1). Supervision shall include visual observation. This requirement was not met evidenced by interviews and records review. C1-C2 were left unattended for approximately 5-10 minutes during transition which poses an immediate risk to the health, safety, or personal rights of 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.
Erin Virrueta
NAME OF LICENSING PROGRAM MANAGER:
Noah Wheeler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/28/2025


LIC809 (FAS) - (06/04)
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