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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 343624247
Report Date: 07/02/2024
Date Signed: 07/02/2024 02:43:52 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2024 and conducted by Evaluator Erwina Pascual-Golamco
PUBLIC
COMPLAINT CONTROL NUMBER: 03-CC-20240624101308
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: 75DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Nancy FugateTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff does not provide adequate supervision to day care children.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erwina Pascual-Golamco, met with Director, Nancy Fugate, for the purpose of opening and closing a complaint investigation for the above allegation. The purpose of today's inspection was explained.

Throughout the course of the investigation, LPA observed staff provide care to children, conducted interviews, and obtained documentation. On 06/17/2024, Director self-reported and submitted an Unusual Incident Report LIC924 that a child was left unattended in the outdoor activity space for approximately 11 minutes according to interviews and record reviews. Director stated staff failed to conduct their attendance counts while transitioning from outside to inside. The staff noticed child was missing when they were doing diaper checks, and staff notified the office immediately of the child's absence. Office staff began looking, and child was found in the play structure in the fenced outdoor play yard. Director stated they are retraining staff on name to face transitions, being aware of the number of children they have, and checking all areas of the yard before going indoors and outdoors. continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
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 4
Control Number 03-CC-20240624101308
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: EXCELSIOR PRESCHOOL GOLD RIVER LLC
FACILITY NUMBER: 343624247
VISIT DATE: 07/02/2024
NARRATIVE
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Furthermore, records review and interview indicated that Director did not report the incident to the child's authorized representative.

Based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the allegation that staff does not provide adequate supervision to day care children is SUBSTANTIATED.

Title 22 Deficiencies are issued on the attached LIC 9099-D page. Director was informed that the Type A deficiency cited today is an immediate civil penalty, for absence of supervision, and is being assessed in the amount of $500. Director shall also 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. Exit interview was conducted with Director, appeal rights were provided, and A notice of site visit was given to Director, who will post it where visible to parents/guardians for 30 days. A signed Acknowledgement of Receipt of the Licensing Report (LIC 9224) must be placed in the child's file for verification.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 03-CC-20240624101308
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: EXCELSIOR PRESCHOOL GOLD RIVER LLC
FACILITY NUMBER: 343624247
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/03/2024
Section Cited
CCR
101229(a)(1)
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101229 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time...shall include visual observation.
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Director (D) stated they are retraining staff on name to face transitions, being aware of the number of children they have, and checking all areas of the yard before going indoors and outdoors. D also revised the class schedule to accomodate a safer transition time. LPA received receipt of training and materials. LPA will conduct a POC visit.
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This requirement was not met as evidenced by:based on observation, interview, and record reviews, Director(D) did not comply with the section cited above as a child was left unattended in the play yard for approximately 11 minutes. D stated that staff failed to conduct their attendance counts while transitioning from outside to inside, which poses an immediate health, safety, or personal rights risk to persons in care.
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Type B
07/16/2024
Section Cited
CCR
101212(f)
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101212 Reporting Requirements (f) The items specified in (d)(1)(A) through (H) above shall also be reported to the child's authorized representative.
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Director stated she understands the reporting requirements and moving forward, incidents will be reported to authorized representatives immediately.
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This requirement was not met as evidenced by: based on interview and record review, Director(D) did not comply with the section cited above as D did not report the incident to the child's authorized representative, 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.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4