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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110699
Report Date: 02/05/2025
Date Signed: 02/05/2025 02:01:47 PM

Document Has Been Signed on 02/05/2025 02:01 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:FUMC PRESCHOOL CHILD CARE CENTERFACILITY NUMBER:
490110699
ADMINISTRATOR/
DIRECTOR:		DIANE WIKSEFACILITY TYPE:
850
ADDRESS:1551 MONTGOMERY DRIVETELEPHONE:
(707) 546-7012
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 48TOTAL ENROLLED CHILDREN: 25CENSUS: 18DATE:
02/05/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Diane WikseTIME VISIT/
INSPECTION COMPLETED:
02:16 PM
NARRATIVE
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An unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Amy Strother in response to a self-reported, lack of supervision incident that resulted in an unexplained injury of a child.

During the initial notification to the Department on 01/24/25, Director, Diana Wikse (D1) stated on a voicemail left on the Child Care Duty Officer line that teacher (S1) was at the sink in the classroom when they heard child (C1) cry, turned around, and observed that C1 was holding her arm. D1 stated on the voicemail that S1 did not see what happened and that it was unclear how C1 was injured. An Unusual Incident Report (UIR) was received from the facility on 01/31/25, stating that a child (C1) received an unexplained injury while in care on 01/24/25. The written UIR states that 11 children were present in the Caterpillar classroom at the time of the incident and that a second teacher (S2) was in the other room changing a diaper.

During today’s visit, LPA met with Facility Representative, Director, Diane Wikse. LPA observed 7 children in the Caterpillar classroom, supervised by 2 teachers, and 11 children in the Butterfly classroom, supervised by 2 teachers, operating within the licensed capacity and ratio requirements. LPA made classroom observations, noting that the children were supervised at all times by one or two teachers. LPA conducted an interview with staff S1.

Based on available information, it has been determined that adequate supervision was not provided on 01/24/25 when staff S2 was out of the classroom changing diapers and S1 had their back turned to the classroom of children, resulting in the unexplained injury of child C1. The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809 Deficiency page. Appeal Rights were provided.

LPA provided handouts on Active Supervision to D1 during the visit.

A notice of site visit was given to D1 and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with facility representative, Diane Wikse

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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 02/05/2025 02:01 PM - It Cannot Be Edited


Created By: Amy Strother On 02/05/2025 at 01:42 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: FUMC PRESCHOOL CHILD CARE CENTER
FACILITY NUMBER: 490110699

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2025
Section Cited
CCR
101229(a)(1)

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Care and Supervision. 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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Director, Diane Wikse (D1) stated that she has a staff meeting scheduled for 02/12/25 and will discuss the topic of supervision and expectations for visual supervision with the staff.
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Based on record review and interview with S1, on 01/24/25 staff S2 was out of the classroom changing diapers and S1 had their back turned to the classroom of children, resulting in the unexplained injury of child C1, which poses a potential risk to the health and safety or personal rights of children in care.
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D1 will submit meeting notes or training materials used during the meeting, along with the signatures of the staff in attendance to LPA Strother's email: amy.strother@dss.ca.gov

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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:Megan Aviles
LICENSING EVALUATOR NAME:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2025


LIC809 (FAS) - (06/04)
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