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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 185406614
Report Date: 06/05/2024
Date Signed: 06/05/2024 10:27:43 AM

Document Has Been Signed on 06/05/2024 10:27 AM - 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 CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:SUSANVILLE STATE PRESCHOOLFACILITY NUMBER:
185406614
ADMINISTRATOR/
DIRECTOR:		TOMSON, MARYFACILITY TYPE:
850
ADDRESS:2005 FOURTH STREETTELEPHONE:
(530) 257-9781
CITY:SUSANVILLESTATE: CAZIP CODE:
96130
CAPACITY: 24TOTAL ENROLLED CHILDREN: 24CENSUS: 13DATE:
06/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:51 AM
MET WITH:Samantha Akerson - Assistant Site Supervisor TIME VISIT/
INSPECTION COMPLETED:
10:38 AM
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An unannounced case management inspection was conducted today at 9:52am by Licensing Program Analyst (LPA), Sydney Sims. LPA met with facility representative Samantha Akerson. In response to an Unusual Incident Report received by the Department on 5/30/24 where a child C1 was outside unsupervised.

The facility representative was interviewed on 6/5/24 at 10:01 and stated that on 5/30/24 Child C1's parent came to pick C1 up and staff realized that child C1 was not in the classroom. Staff found C1 outside playing alone. Facility Representative stated that child left the classroom on their own.

During today’s inspection, the facility was toured and LPA Sims observed 13 children in care.

Based on information reported and interview conducted the following deficiency is being cited on the LIC809-D: 101229(a)(1) No child(ren) shall be left without the supervision of a teacher at any time.
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: SUSANVILLE STATE PRESCHOOL
FACILITY NUMBER: 185406614
VISIT DATE: 06/05/2024
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LPA Sydney Sims informed facility representative Samantha Akerson that this report dated 6/5/24 documents One Type A citation(s) 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.

LPA Sydney Sims informed the facility representative to provide a copy of this licensing report dated 6/5/24 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 the child's file for verification.



Exit interview conducted and report was reviewed with the facility representative Samantha Akerson. Appeal Rights were provided
SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Sydney Sims
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2024 10:27 AM - It Cannot Be Edited


Created By: Sydney Sims On 06/05/2024 at 10:22 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: SUSANVILLE STATE PRESCHOOL
FACILITY NUMBER: 185406614

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2024
Section Cited
CCR
101229(a)(1)

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No child(ren) shall be left without the supervision of a teacher at any time...

This requirement was not met as evidence by:
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Facility willc have parents of children currently enrolled and children who enroll for the next 12 months sign LIC 9224.
Facility staff will conduct a staff meeting on supervison and write statement about meeting. All staff will sign statment and send copy to LPA Sims via email.
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Based on information reported and interview conducted the facility did not comply with the section cited above in 1 count of leaving a child unsupervised.
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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:Sydney Sims
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


LIC809 (FAS) - (06/04)
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