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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493005596
Report Date: 09/19/2024
Date Signed: 09/19/2024 01:37:27 PM

Document Has Been Signed on 09/19/2024 01:37 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:ROSEBUD PRESCHOOLFACILITY NUMBER:
493005596
ADMINISTRATOR/
DIRECTOR:		AMBER ASHWORTH-HIXFACILITY TYPE:
850
ADDRESS:2500 PATIO COURTTELEPHONE:
(707) 544-8600
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 34TOTAL ENROLLED CHILDREN: 48CENSUS: 22DATE:
09/19/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:28 AM
MET WITH:Amber Ashworth-HixTIME VISIT/
INSPECTION COMPLETED:
01:47 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 involving child C1 and five staff, S1-S5. The incident occurred on 09/09/24. During today’s visit, the LPA met with Center Director, Amber Ashworth-Hix (D1) and Site Supervisor Nicole Levesque (D2) to discuss the incident.

It was reported on 09/09/24 by Site Supervisor Nicole Levesque that on 09/09/24, child C1 was left on the center’s playground, which is fully fenced, without staff supervision for 8 minutes. The Site Supervisor reported that 4 staff S1-S4 were on the playground with 19 children and escorted children inside to wash hands for lunch at 12:00pm. The Site Supervisor reported that S1-S4 transitioned indoors for lunch time with the 18 other children, leaving C1 outside. The Site Supervisor reported that staff S5 was coming back from a lunch break and while setting out lunches noticed that child C1 was not in the hand washing line or at the tables and began to look for C1. The Site Supervisor’s report stated that S5 looked outside and found C1 standing on a stump behind the apple tree, then brought C1 inside to join the group at 12:08pm.

This self-reported incident was reported to CCLD as required per regulations. The Site Supervisor reported that this incident was also reported to the child’s (C1’s) authorized representative. The Site Supervisor reported that they discussed with the teachers the need for additional play yard sweeps when transitioning inside, agreeing to one sweep as the children are lined up and one additional sweep after all children are inside the classroom. The report also stated that teachers will perform a count after every transition from one space to another. The Site Supervisor reported that additional training was provided to staff regarding the topics of care and supervision and indoor to outdoor and outdoor to indoor transitions. During today’s case management visit, no children were observed to be left without supervision. LPA observed active supervision of 21 children and observed teachers performing head counts and sweeps as stated in the report. LPA interviewed D1 who was able to explain what went wrong and how the new procedure in place will prevent the incident from re-occurring.

Continue on LIC809-C

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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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: ROSEBUD PRESCHOOL
FACILITY NUMBER: 493005596
VISIT DATE: 09/19/2024
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Based on available information, it has been determined that staff S1-S4 did not provide adequate supervision to child C1 during the incident on 09/09/2024. The following violation of the California Code of Regulations, Title 22; Division 12, was observed: see LIC 809D.

This report was read and reviewed with facility representative Site Supervisor, Nicole Levesque or Center Director, Amber Ashworth-Hix.

Notice of site visit shall be posted for 30 days. Appeal rights provided.

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

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2024 01:37 PM - It Cannot Be Edited


Created By: Amy Strother On 09/19/2024 at 12:55 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: ROSEBUD PRESCHOOL
FACILITY NUMBER: 493005596

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2024
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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This deficiency was cleared during today's case management visit. The Director provided a copy of the written transition procedures staff now follow for transitions indoor to outdoor and outdoor to indoors. LPA observed the transition in progress during today’s visit.
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Based on the Site Supervisor's written unusual incident report (UIR) submitted to CCLD on 09/09/24, stating that on 09/09/24 at approximately 12:00pm, child C1 was left without supervision of a teacher for approximately eight minutes while on the preschool playground before being reunited with their class. The Site Supervisor reported that C1's class transitioned indoors while C1 remained outdoors on the fully fenced play yard, which posed a potential health and safety risk to a child 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: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


LIC809 (FAS) - (06/04)
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