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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313620611
Report Date: 02/14/2024
Date Signed: 02/14/2024 02:58:02 PM

Document Has Been Signed on 02/14/2024 02:58 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CATALYST KIDS - COBBLESTONEFACILITY NUMBER:
313620611
ADMINISTRATOR:SARA LEFFLERFACILITY TYPE:
840
ADDRESS:5740 COBBLESTONE DRTELEPHONE:
(916) 632-0140
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY: 50TOTAL ENROLLED CHILDREN: 50CENSUS: 16DATE:
02/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sara LefflerTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jeremey McClain met with facility representative Sara Leffler for an unannounced Case Management Inspection regarding an Unusual Incident Report.

LPA observed 16 children supervised by three staff members.

It was reported that on 02/07/2024, a child was left unsupervised in the bathroom for approximately 1-2 minutes. This occurred when Staff 1 took eight children to bathroom and realized they had forgot Child 1 upon returning to the classroom. Staff immediately went to retrieve the child once this was realized. A janitor had begun to escort the child back to classroom and was met by Staff 1. Child 1 did not suffer any injuries.

Type A citation
LPA Jeremey McClain informed facility representative Sara Leffler that this report dated 02/07/2024 documents a Type A citation(s) which shall be posted for 30 consecutive days as there was an immediate risk to the health, safety, or personal rights of children in care.
Also, LPA Jeremey McClain informed facility representative Sara Leffler to provide a copy of this licensing report dated 02/07/2024 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.

Posting Requirements
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

LPA provided a copy of appeal rights.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Jeremey McClain
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
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 02/14/2024 02:58 PM - It Cannot Be Edited


Created By: Jeremey McClain On 02/14/2024 at 02:37 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CATALYST KIDS - COBBLESTONE
FACILITY NUMBER: 313620611

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/15/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for providing supervision. (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) and 101230(c)(1). Supervision shall include visual observation.
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Training with staff was conducted regarding expectations of supervision. A plan of action was created and reviewed with staff to prevent the incident from occurring again.
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This requirement was not met as evidenced by unusual incident report received on 02/07/2024 and interview with staff. Child 1 was left unsupervised in bathroom for approximately 1-2 minutes. This is considered an immediate risk to health and safey 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.
SUPERVISOR'S NAME:Keven Peters
LICENSING EVALUATOR NAME:Jeremey McClain
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
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