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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483001824
Report Date: 08/12/2022
Date Signed: 08/12/2022 04:58:28 PM

Document Has Been Signed on 08/12/2022 04:58 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KINDERCARE LEARNING CENTERFACILITY NUMBER:
483001824
ADMINISTRATOR:ERIKA RAMIREZFACILITY TYPE:
830
ADDRESS:1101 ROSE DRIVETELEPHONE:
(707) 745-0916
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY: 34TOTAL ENROLLED CHILDREN: 34CENSUS: 15DATE:
08/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Erika Silva, DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), M. Trinh made a Case Management visit and met with the Director, Erika Silva (D1) to deliver this report and citation. During the course of a complaint investigation, LPA Trinh obtained evidence showing that a child's personal rights were violated by Teacher on 07/12/2022.
On 07/25/2022, LPA interviewed two staff whose statements confirmed that on 07/12/2022
a Teacher was witnessed to have pushed Child 1 (C1) in the back of head causing his forehead to hit the doorknob. C1 was not physically injured from the incident.
An internal investigation by Director was made and concluded that Teacher is terminated. LPA Trinh received copy of termination letter dated 07/29/2022. LPA Trinh received copies of staff interviews written by Director.
The incident occurred on 07/12/2022 and Unusual Incident Report (UIR) was received to Communty Care Licensing on 08/03/2022. Reporting requirements will be cited.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Mary Trinh
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2022
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 08/12/2022 04:58 PM - It Cannot Be Edited


Created By: Mary Trinh On 08/12/2022 at 02:20 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
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KINDERCARE LEARNING CENTER
FACILITY NUMBER: 483001824

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited
CCR
101223(a)(3)

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(a) The licensee shall ensure that each child is accorded the following personal rights:
(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse or other actions of a punitive nature including but not limited to: interference with functions of daily living including eating, sleeping or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Director terminated the Teacher on July 29, 2022.
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Based on Director and Staff interviews which corroborated the facility did not comply with the requirements of personal rights. This poses/posed a potential health, safety and/or personal rights risk to the children in care.
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Type B
08/12/2022
Section Cited
HSC101212(a)(d)(1)(C)

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(a) Each licensee or applicant shall furnish to the Department reports as required by the Department including, but not limited to, the following:

(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.

(1) Events reported shall include the following:
(C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child.

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Director will always email to CCL UIR's and not through post office mail.
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UIR occurred on 07/12/2022 and UIR was received to CCL on 08/03/2022. This poses a potential safety to the 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:Alexis Hollon
LICENSING EVALUATOR NAME:Mary Trinh
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2022


LIC809 (FAS) - (06/04)
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