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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
493006901
Report Date:
04/04/2024
Date Signed:
04/04/2024 03:53:30 PM
Document Has Been Signed on
04/04/2024 03:53 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
CCLD Regional Office
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
4CS WILLOW CREEK STATE PRESCHOOL
FACILITY NUMBER:
493006901
ADMINISTRATOR/
DIRECTOR:
SCHAEFER, PAULA
FACILITY TYPE:
850
ADDRESS:
2536 MARLOW ROAD
TELEPHONE:
(707) 570-2607
CITY:
SANTA ROSA
STATE:
CA
ZIP CODE:
95403
CAPACITY:
32
TOTAL ENROLLED CHILDREN:
32
CENSUS:
7
DATE:
04/04/2024
TYPE OF VISIT:
Case Management - Incident
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
03:35 PM
MET WITH:
Olga Luvano
TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Glenn Ouye arrived to speak with staff regarding an incident which occurred 3/28/24. Child C1 reported to parent that the child fell off a bike and that the child's head was hurting.
The facility does have tricycles. The staff did not witness C1 being injured and C1 did not notify staff that C1 was injured. Teachers observed that C1 appeared to be tired and the child was picked up within 10 minutes of the teachers checking on C1.
Child was taken for medical care because C1 told parent that head was hurting. C1 was diagnosed with a concussion
The was Site Supervisor was not present at the time of inspection and the teacher on site was not present on 3/28/24 and did not have direct knowledge of the incident but did hear about the incident.
LPA will return at at a future date to speak with the Site Supervisor.
SUPERVISORS NAME
:
Leslie Lepori
LICENSING EVALUATOR NAME
:
Glenn Ouye
LICENSING EVALUATOR SIGNATURE
:
DATE:
04/04/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/04/2024
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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