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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493006542
Report Date: 02/06/2025
Date Signed: 02/06/2025 04:38:26 PM

Document Has Been Signed on 02/06/2025 04:38 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:NORTH BAY CHILDREN'S CENTER P/S - MCDOWELLFACILITY NUMBER:
493006542
ADMINISTRATOR/
DIRECTOR:
LUEZA, KRISTIEFACILITY TYPE:
850
ADDRESS:405 SOUTH MCDOWELLTELEPHONE:
(707) 763-2000
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 39TOTAL ENROLLED CHILDREN: 31CENSUS: 27DATE:
02/06/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:07 PM
MET WITH:Kristie Lueza, Site SupervisorTIME VISIT/
INSPECTION COMPLETED:
03:58 PM
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A Case Management inspection was conducted at the facility by Licensing Program Analyst (LPA) Y. Yang in response to an Unusual Incident Report (UIR) received 02/03/2025 involving a child sustaining a head injury while in care. During today’s visit, the LPA met with the facility’s site supervisor, Kristie Lueza, to discuss the incident and obtain additional details. The site supervisor reported that on 01/20/25, child C1 was standing on a child sized couch in the classroom and fell backwards and landed on their head on the classroom's carpeted floor. The site supervisor reported that C1 did not cry but lost consciousness for approximately three seconds. The site supervisor reported that C1’s authorized representative, a teacher at the facility, was notified and immediately transported C1 to be examined by a medical professional. The site supervisor reported that C1 did not have any visible injuries but was evaluated for a concussion. The site supervisor reported that C1 did not show any concussion symptoms and was discharged the same day and cleared to return to the center.

During today's case management visit, the LPA reviewed with the site supervisor the facility's child supervision policies. The LPA inspected the classroom and observed that the couch in the classroom is age appropriate and less than one foot from the ground. This incident was reported to CCLD and the child’s authorized representative as required per regulations.

Based on available information, it has been determined that there was no evidence of violations of regulations that occurred that lead to the child's injury. This report was read and reviewed with the site supervisor, Kristie Lueza. There were no Title 22 violations cited during today's case management visit. The Notice of Site Visit shall be posted for 30 days.

SUPERVISORS NAME: Megan Aviles
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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