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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623422
Report Date: 10/11/2023
Date Signed: 10/11/2023 03:25:31 PM

Document Has Been Signed on 10/11/2023 03:25 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:BUILDING KIDZ OF RANCHO CORDOVAFACILITY NUMBER:
343623422
ADMINISTRATOR:MANCHESTER, ANGELINAFACILITY TYPE:
850
ADDRESS:1941 ZINFANDEL DRIVETELEPHONE:
(916) 706-2653
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 19DATE:
10/11/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Danielle LawTIME COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erwina Pascual-Golamco, met with Director Danielle Law, for a case management inspection regarding an incident that happened on 7/20/23. Census included 19 preschool children supervised by 3 staff. Purpose of the inspection was explained.

LPA received an incident that happened on 7/20/23 and the department did not receive notification from Director or facility representative within the next business day and LIC624 within 7 working days. LPA provided technical assistance regarding reporting requirements, and provided resources.

Title 22 Deficiency has been cited for reporting requirements. Exit interview was conducted, appeal rights were provided, and a Notice of Site (NOS) visit was given to Director, who will post it where visible to parents/guardians for 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2023
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 10/11/2023 03:25 PM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 10/11/2023 at 11:45 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BUILDING KIDZ OF RANCHO CORDOVA
FACILITY NUMBER: 343623422

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2023
Section Cited
CCR
101212(d)(1)(C)

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101212 Reporting Requirements (d)...any of the events specified in (d)(1) below, a report shall be made to the dept. by telephone or fax within the dept...next working day...In addition, a written report...submitted...to the dept...within seven days...(C)Any unusual incident ...that threatens...or safety of any child.
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LPA reminded Director of the reporting requirements, and provided resources. Director will email LPA attestation statement that they understand the reporting requirements and will comply moving forward by 4PM of POC due date.
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This requirement was not met as evidenced by: based on interview, and record review, Director did not comply with the section cited above as incident on 7/20/23 was not reported to the dept. the next working day, which poses a potential health, safety, or personal rights risk to persons 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:Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2023


LIC809 (FAS) - (06/04)
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