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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110022
Report Date: 11/07/2023
Date Signed: 11/07/2023 04:23:47 PM

Document Has Been Signed on 11/07/2023 04:23 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
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:A SPECIAL PLACEFACILITY NUMBER:
490110022
ADMINISTRATOR:BLANCA HERNANDEZFACILITY TYPE:
850
ADDRESS:1128 EDWARDS AVENUETELEPHONE:
(707) 523-2337
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 30TOTAL ENROLLED CHILDREN: 18CENSUS: 13DATE:
11/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Blanca HernandezTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Amy Strother made an unannounced case management visit to the facility after receiving an Unusual Incident Report (UIR) from the facility on 10/27/23, stating that a three year old child, C1 eloped from the facility on 10/26/2023. LPA met with facility representative, Blanca Hernandez (D1) to discuss the UIR.

D1 stated, as written in the UIR, that C1 wandered away from the outdoor playground, where two staff, D1 and S1 were present. D1 stated that one staff, (S2) was inside of the classroom changing a diaper and another staff (S3) was cooking lunch in the kitchen. During today's visit, LPA conducted an interview with D1 who stated that on 10/26/23 she had been assisting C1, helping to put on C1’s socks and shoes, when she observed a child across the yard in the sandbox display unsafe behavior toward another child. S1 stated that she ran across the yard from to prevent an incident from occurring in the sandbox and left C1's side. At the time this occurred, D1 stated that S1 was pushing children on the swing. D1 stated that when she turned back to make contact with C1, she did not see C1 on the play yard. Based on today's interview with D1, D1 immediately asked S1 if she had seen C1, who said "no", S1 looked inside the closed "blue room" classroom located outside and after not seeing C1, called for help from S2 & S3 through the open classroom window. D1 stated that while S1 was doing that, she went out the outdoor gate that leads to the parking lot, which was closed at the time. D1 stated that the door to the classroom from the yard was closed during the time C1 was not visible and the door is only accessible to open with a code entered by staff. D1 stated that once she got out the gate she could see down then driveway from the parking lot and observed C1 to be down the driveway standing with a passerby (A1). A1 did not give his name, but identified himself as a neighbor living near the school, stating that he was walking home from the store and noticed C1 alone in the driveway. D1 reunited with C1, who had not sustained any injuries. D1 one stated during today's interview that the whole incident was less than one minute. LPA and D1 measured the distance from the gate to the area C1 was found, the distance measured 100 feet.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: A SPECIAL PLACE
FACILITY NUMBER: 490110022
VISIT DATE: 11/07/2023
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A review of sign-in/sign-out records indicate that 16 children were in care on 10/26/23, proofing that the facility was operating within the required supervision ratios when the incident occurred. Based on interview conducted and measurements taken, C1 left the play ground alone and was without supervision, about 100 feet away, for less than 1 minute.

The following violation of the California Code of Regulations, Title 22; Division 12, has occurred: see LIC 809D. Appeal Rights were provided.

LPA Strother informed facility representative Blanca Hernandez that this report dated 11/07/23 documents one of Type A citation. Type A citations shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Strother informed the facility representative to provide a copy of this licensing report dated 11/07/23 that documents any Type A citation(s) 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. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/07/2023 04:23 PM - It Cannot Be Edited


Created By: Amy Strother On 11/07/2023 at 03:34 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: A SPECIAL PLACE
FACILITY NUMBER: 490110022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2023
Section Cited
CCR
101229(a)(1)

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(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, except as specified in Sections 101216.2(e)(1) and 101230(c)(1). Supervision shall include visual observation.

This requirement was not met as evidenced by:
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D1 will implement a policy for staff in a typed letter on how to position themselves on the play yard to ensure that children do not exit the yard unsupervised and also ask parents to be sure and close doors and gates when coming and going by 11/08/23. Additionally D1 will conduct a staff meeting on 11/08/23 to include the topic of supervision, providing LPA Strother signatures from staff who attended the training. D1 stated she will be adding alarms to all exits that lead outside, and providing proof of training and alarms added by 11/21/23. Submitting to amy.strother@dss.ca.gov
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Based on self reported record, C1 left the center without supervision on 10/26/23 and was found by a neighbor and D1 in the unfenced facility driveway/parking lot that leads to the street. This poses an immediate health, safety or personal rights risk 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:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2023


LIC809 (FAS) - (06/04)
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