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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173010488
Report Date: 09/16/2024
Date Signed: 09/16/2024 02:02:38 PM

Document Has Been Signed on 09/16/2024 02:02 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KONOCTI USD CHILD DEVELOPMENT CENTER-P/SFACILITY NUMBER:
173010488
ADMINISTRATOR/
DIRECTOR:		ANGEL COPPAFACILITY TYPE:
850
ADDRESS:4750 GOLF AVENUETELEPHONE:
(707) 994-6475
CITY:CLEARLAKESTATE: CAZIP CODE:
95422
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 18DATE:
09/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Director, Angel CoppaTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 09/16/2024, Licensing Program Analysts (LPA), Sebastian Phouthaovong made an unannounced Case Management visit in response to a self reported, lack of supervision Unusual Incident Report (UIR). UIR was notified to Community Care Licensing on 09/10/2024. The incident was regarding child being unsupervised for approximately 10 minutes located in the outdoor play area. LPA met with Director, Angel Coppa and spoke with her the purpose of today's visit.

During today's inspection, LPA toured the facility inside and out and observed 18 children being supervised by 6 staff members. LPA conducted interviews with the Director and two staff members. Director stated while switching staff members to assist with transitioning the daycare children from the outdoor play area to the inside classroom, a child was left unsupervised; the child was immediately found. Director stated the child was checked on and the child's authorized representative was notified; being understanding of the incident. Licensee stated the incident was addressed with all staff and have updated the facility supervision procedure to enure no child is left unattended without a staff member. Staff interview corroborated Director's statement.

LPA received a hardcopy of the UIR during the visit.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Director, Angel Coppa

The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809 D. Appeal rights were given.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
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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Document Has Been Signed on 09/16/2024 02:02 PM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 09/16/2024 at 01:41 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KONOCTI USD CHILD DEVELOPMENT CENTER-P/S
FACILITY NUMBER: 173010488

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/07/2024
Section Cited
CCR
101229(a)(1)

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101229(a)(1) Responsibility for Providing Care and Supervision: (a) The licensee shall provide care and supervision....(1) No child(ren) shall be left without the supervision of a teacher at any time,...This requirement was not met as evidenced by
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Director stated she will submit a summary of the staff meeting that was conducted regarding supervision, along with proof of attendance to the LPA by 10/07/24.
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Based on the facility's admission of a unusual incident report (UIR) Notification on 09/10/2024, a child was unsupervised for approximately 10 minute located at the outdoor play area.
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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:Leslie Lepori
LICENSING EVALUATOR NAME:Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024


LIC809 (FAS) - (06/04)
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