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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343624247
Report Date: 02/06/2023
Date Signed: 02/06/2023 12:46:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2023 and conducted by Evaluator Erwina Pascual-Golamco
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20230131111822
FACILITY NAME:EXCELSIOR PRESCHOOL GOLD RIVER LLCFACILITY NUMBER:
343624247
ADMINISTRATOR:FUGATE, NANCYFACILITY TYPE:
850
ADDRESS:2317 GOLD MEADOW WAYTELEPHONE:
(916) 730-8757
CITY:GOLD RIVERSTATE: CAZIP CODE:
95670
CAPACITY:118CENSUS: 23DATE:
02/06/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Nancy FugateTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Children have access to hazardous material.
INVESTIGATION FINDINGS:
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On 2/6/2023, at approximately 930 AM, Licensing Program Manager Natalie Dunaway and Licensing Program Analyst (LPA) Erwina Pascual-Golamco met with Director Nancy Fugate for an unannounced complaint visit, regarding children having access to a hazardous material (bleach).

During today's inspection, LPM and LPA conducted interviews.

It was determined that on 1/20/23, a child spilled accessible bleach on their shirt. The bleach was used for disinfecting materials and was left overnight on a classroom counter.

The allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 03-CC-20230131111822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: EXCELSIOR PRESCHOOL GOLD RIVER LLC
FACILITY NUMBER: 343624247
VISIT DATE: 02/06/2023
NARRATIVE
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A Type “A” violation was issued today. The center is informed to provide a copy of the Evaluation Report and the Type “A” Deficiency cited to the parents and guardians of children currently enrolled in care and to parents of newly enrolled children during the next 12 months. A signed and dated LIC 9224 shall be maintained in all Children's files. This report and appeal rights were provided and reviewed with the licensee. Notice of Site Visit shall remain posted for 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 03-CC-20230131111822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: EXCELSIOR PRESCHOOL GOLD RIVER LLC
FACILITY NUMBER: 343624247
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2023
Section Cited
CCR
101238(g)
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101238 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.
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Dicector Nancy Fugate conducted staff training on the proper use and storage of chemicals. Staff are also checking for hazards in the mornings. and evenings.

Deficiency cleared as of today's visit.
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On 1/20/22 bleach was accessible to 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.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3