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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343620245
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:40:29 PM

Document Has Been Signed on 07/09/2024 04:40 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:GODDARD SCHOOL, THEFACILITY NUMBER:
343620245
ADMINISTRATOR/
DIRECTOR:		KATHRYN DRAKEFACILITY TYPE:
850
ADDRESS:251 OUTCROPPING WAYTELEPHONE:
(916) 936-0377
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY: 132TOTAL ENROLLED CHILDREN: 132CENSUS: 104DATE:
07/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Kaylee AgamanTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jennifer Velasco met with Facility Representative, Kaylee Agaman (Representative), for a case management visit regarding an incident that occurred on 06/26/2024. The purpose of the visit was explained to Representative. The facility representative self-reported an incident to the department on 06/27/2024 by submitting a written Unusual Incident Report (UIR) LIC 624. Per the UIR, a child (Child1) was left in the classroom without supervision for approximately 17 minutes when the children transitioned from the classroom to the outdoor play yard. The timeline of the absence of supervision was determined by facility staff (Staff1), who noticed Child1's absence from the playground and opened the door to the classroom to retrieve Child1. During today's inspection, LPA observed the classroom and play yard and interviewed staff. Representative and staff stated that face to name roll call was not done by Staff1 during the transition to outside. Representative stated that Staff1's employment at the facility was terminated 06/26/2024.

Based on observation, interview, and record reviews, a Title 22 Deficiency has been issued on the attached LIC 809-D page. Representative was informed that the Type A deficiency cited today requires Representative to provide a copy of this licensing report 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. Representative was also advised that a signed Acknowledgement of Receipt of the Licensing Report (LIC 9224) must be placed in the child's file for verification.

The facility has been assessed a $1000 civil penalty for this repeat occurrence of absence of supervision.

Exit interview was conducted with Facility Representative Kaylee Agaman, and appeal rights were provided. A notice of site visit was given to Facility Representative, who will post it where visible to parents/guardians for 30 days.

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Jennifer Velasco
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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 07/09/2024 04:40 PM - It Cannot Be Edited


Created By: Jennifer Velasco On 07/09/2024 at 12:22 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: GODDARD SCHOOL, THE
FACILITY NUMBER: 343620245

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

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The licensee shall provide care and supervision as necessary to meet the children's needs. No child(ren) shall be left without the supervision of a teacher at any time ... Supervision shall include visual observation. This requirement is not met as evidenced by:
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Representative stated the staff was terminated the same day. Representative also stated they will develop a detailed written plan for ensuring this does not occur again and will email the plan to LPA by close of business POC due date:
jennifer.velasco@dss.ca.gov
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Facility self reported that on 06/26/2024, during a transition from the classroom to the playground, Child1 was left unattended in the Octopus classroom for approximately 17 minutes. This is an immediate health and safety risk to 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:Natalie Dunaway
LICENSING EVALUATOR NAME:Jennifer Velasco
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
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