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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 233009794
Report Date: 04/16/2025
Date Signed: 04/16/2025 01:51:30 PM

Document Has Been Signed on 04/16/2025 01:51 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 CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BOONT TRIBE COMMUNITY SCHOOL P/SFACILITY NUMBER:
233009794
ADMINISTRATOR/
DIRECTOR:		SEASHA ROBBFACILITY TYPE:
850
ADDRESS:8300 HIGHWAY 128TELEPHONE:
(707) 895-3590
CITY:PHILOSTATE: CAZIP CODE:
95466
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
04/16/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:52 AM
MET WITH:Seasha RobbTIME VISIT/
INSPECTION COMPLETED:
12:48 PM
NARRATIVE
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Licensing Program Analyst (LPA) Robert Maciel made a case management visit to the facility for the purpose of following up on an Unusual Incident Report that was self-reported to the department on 4/11/25 and met with Director Seasha Robb (D1).

As reported in the Unusual Incident Report, on 4/9/25 at around 9:30 AM a child (C1) noticed a large crack in a tree trunk outside in the playground. Staff kept children away from the tree and called an arborist and scheduled an appointment to assess the tree. At 11:20 AM, the tree fell down on a play structure, destroying it while all staff and children were inside. The arborist came to the facility at 2:30 PM to assess the damage and clean-up. On 4/10/25, the tree was removed by a tree service company. The demolished play structure would be removed the weekend of 4/12/25.

During today's inspection, the facility was toured and LPA spoke with staff. LPA observed that the demolished play structure debris was present on the side of the playground. Director stated that the playstructure will be removed by Friday, 4/18/25. LPA asked Director about why the incident was not reported to the department within 24 hours. Director stated that she believed because no children were harmed by the tree fall, the incident was not required to be reported.

The following deficiencies were observed during today's visit (see LIC809D). Exit interview given and report was read with Director Seasha Robb . A notice of site visit was given and must remain posted for 30 days. Failure to do so shall result in an immediate civil penalty of $100.
NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Robert Maciel
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2025
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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Document Has Been Signed on 04/16/2025 01:51 PM - It Cannot Be Edited


Created By: Robert Maciel On 04/16/2025 at 01:20 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: BOONT TRIBE COMMUNITY SCHOOL P/S
FACILITY NUMBER: 233009794

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2025
Section Cited
CCR
101212(d)

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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...

This requirement was not met as evidenced by:
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LPA reviewed the reporting requirements with Director and director submitted a written statement to LPA attesting to her understanding of the reporting requirements.
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Based on interview, Director did not report the incident in which a tree fell in the playground during day care hours, which poses a potential health, safety, or personal rights risk to persons in care.
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Type B
04/22/2025
Section Cited
CCR101238.2(d)(2)

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Free of hazards including, but not limited to, holes, broken glass and other debris, and dry grasses that pose a fire hazard.

This requirement was not met as evidenced by:
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Director stated that the debris from the play structure would be removed by Friday 4/18/25 and that she would send a picture of the area once the debris is removed by 4/22/25.
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Based on observation, Director did not remove the debris from the outdoor play area or create a barrier to prevent access to day care children.
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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.
Melchisedeck Augustin
NAME OF LICENSING PROGRAM MANAGER:
Robert Maciel
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2025


LIC809 (FAS) - (06/04)
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