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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624788
Report Date: 11/25/2024
Date Signed: 11/25/2024 02:31:45 PM

Document Has Been Signed on 11/25/2024 02:31 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:
343624788
ADMINISTRATOR/
DIRECTOR:		PU, WILLIAMFACILITY TYPE:
850
ADDRESS:3370 ZINFANDEL DRIVETELEPHONE:
(916) 861-0906
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 144TOTAL ENROLLED CHILDREN: 144CENSUS: 94DATE:
11/25/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Katelynn LeeTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erwina Pascual-Golamco, met with Director, Katelynn Lee, for a case management inspection regarding an incident on 10/30/24. Purpose of the inspection was explained.

Director self reported and submitted a written Unusual Incident Report LIC624, that on 10/30/24, at approximately 8:50 AM, a child left a classroom and walked down the hallway to another classroom. According to Director, a parent/guardian saw the child walk down the hall and opened the door for the child to go in the other classroom leaving the child without supervision of a staff for approximately 1 minute. Staff member informed Director about the incident, and Director self reported the incident to the department, interviewed staff and witnesses, informed parent/guardian of child and took necessary steps/actions regarding incident.

Based on interview and record reviews, Title 22 Deficiency has been issued on the attached LIC809-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 Director, who will post it where visible to parents/guardians for 30 days. A signed Acknowledgement of Receipt of the Licensing Report (LIC9224) must be placed in the child's file for verification.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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 11/25/2024 02:31 PM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 11/25/2024 at 08:34 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: GODDARD SCHOOL, THE
FACILITY NUMBER: 343624788

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2024
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 reviewed strategies with staff regarding active supervision, staff have developed a plan to ensure supervision in their classroom, staff are doing their name to face, and staff have assigned stations in the classroom to monitor doors. Corrections have been made since incident.
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This requirement is not met as evidenced by: Based on interview, and record reviews, Director (D) did not comply with the section cited above as (D) self reported to the dept. and submitted an Unusual Incident Report (UIR) on 10/30/24 that a child left a classroom and walked down the hallway to another classroom without staff supervision for approximately 1 minute, which poses an immediate 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: 11/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2024


LIC809 (FAS) - (06/04)
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