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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 483002942
Report Date: 01/06/2026
Date Signed: 01/06/2026 12:22:16 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/24/2025 and conducted by Evaluator Robert Maciel
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20250924142353
FACILITY NAME:HEAD START - LARSENFACILITY NUMBER:
483002942
ADMINISTRATOR:HARVEY, JOYFACILITY TYPE:
850
ADDRESS:1707 CALIFORNIA DRIVE RM 3TELEPHONE:
(707) 304-2225
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:28CENSUS: 16DATE:
01/06/2026
UNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Shahla ForsatiTIME COMPLETED:
12:29 PM
ALLEGATION(S):
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Lack of supervision resulting in day care child getting an object stuck in their nose.
INVESTIGATION FINDINGS:
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A follow-up complaint investigation was made by Licensing Program Analysts (LPAs), Robert Maciel and Jessica Gaumann, to deliver complaint investigation findings. Licensing Program Analyst (LPA) Cindy Castro made the initial investigation visit on 10/1/25. It was alleged that lack of supervision resulted in a day care child getting an object stuck in their nose, specifically playdough.

During the course of the investigation, LPAs reviewed facility documents and conducted interviews with the director Shahla Forsati (CD), 4 staff (RM, S1, S3, S4) and 4 adults (RP, A1, A2, A3) from 10/01/2025 through 12/29/2025. Interviews with S1, S3, S4, RP, and A2 provided mixed accounts of the incident that occured. Interviews indicate that while an incident did occur on 8/19/25 in which a child, (C1) had stuck playdough in their nose, it is not clear whether the incident was a direct result of lack of supervision from staff in the classroom.
Continued on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melchisedeck Augustin
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
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 01-CC-20250924142353
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HEAD START - LARSEN
FACILITY NUMBER: 483002942
VISIT DATE: 01/06/2026
NARRATIVE
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Continued from LIC9099

Based on the information gathered during this investigation, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the allegations occurred and therefore are determined to be unsubstantiated. There were no Title 22 deficiencies cited. This report was reviewed and discussed with Director, Shahla Forsati (CD). Appeal rights were provided. Notice of Site Visit shall be posted for 30 days from today's visit.
SUPERVISORS NAME: Melchisedeck Augustin
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4