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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008727
Report Date: 02/21/2024
Date Signed: 02/21/2024 02:32:02 PM

Document Has Been Signed on 02/21/2024 02:32 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 GOLD RIDGE PRESCHOOLFACILITY NUMBER:
493008727
ADMINISTRATOR:COPELAND, JENNYFACILITY TYPE:
850
ADDRESS:1455 GOLF COURSE DRIVETELEPHONE:
(707) 586-1253
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 71TOTAL ENROLLED CHILDREN: 44CENSUS: 27DATE:
02/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Claudia Avalos, Site SupervisorTIME COMPLETED:
01:55 PM
NARRATIVE
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A follow-up case management visit to the facility was made today by Licensing Program Analyst (LPA) Y. Yang in response to a child elopement incident at the facility on 01/24/24. During today’s follow-up visit, the LPA met with the site supervisor, Claudia Avalos. During the initial case management visit on 02/14/24, the LPA interviewed facility staff S1-S5. The LPA interviewed adult A1 on 02/15/24 and A2 on 02/21/24.

Based on the incident report submitted by the facility, it was reported that on 01/24/24 at approximately 10:30am, child C1 eloped from the facility and was found outside by the classroom’s entrance door closest to Golf Course Drive by adult A1, who was leaving the facility. Child C1’s classroom is adjacent to the main road and public sidewalk. The front exterior area of the classroom is not fenced or gated. The site supervisor reported that there was a total of 26 children and four facility staff and three specialized aides from the Cotati-Rohnert Park School District in the classroom at the time of the incident. The site supervisor reported that this incident occurred during circle time, which was being held in the center of the classroom. The site supervisor reported that staff did not observe C1 leave the classroom or open the classroom door. The classroom’s entrance door is in the corner of the room. Staff that were interviewed estimate that child C1 was left alone and without staff supervision outside the classroom for up to five minutes. Staff stated that they do not believe C1 left the area immediately outside the door. Staff stated that C1 did not appear to be upset or distressed when found. The site supervisor stated that C1 does not have a history of eloping or attempting to elope from the facility. The site supervisor stated that C1 has a history of getting up and walking around the classroom during circle time, however.

The site supervisor reported that C1’s authorized representative was notified immediately. This incident was self-reported by the facility on 01/25/24 and a written Unusual Incident Report (UIR) was received by the Department on 01/29/24. The site supervisor reported that after this incident, the facility added an electronic door chime on the exit door in the classroom and provided additional training to staff during a staff meeting covering the topics of care and supervision and communication.

California Code of Regulations, Title 22 is being cited on the attached LIC 9099-D. The exit interview was conducted, and this report was read and discussed with the site supervisor, Claudia Avalos. Appeal rights were provided. The Notice of Site Visit shall be posted for 30 days.

Reports citing Type A violations are to be provided to parents/guardians of children currently enrolled by the next business day or the next day the children are in care, and to parents/guardians of children newly enrolled at the facility for the next 12 months from the date of this report. Parents/guardians must sign form LIC 9224 to be kept in each child's file.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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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Document Has Been Signed on 02/21/2024 02:32 PM - It Cannot Be Edited


Created By: Yang Yang On 02/21/2024 at 12:44 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: 4CS GOLD RIDGE PRESCHOOL
FACILITY NUMBER: 493008727

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2024
Section Cited
CCR
101229(a)(1)

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Responsibility for Providing Care and Supervision. The licensee shall provide care and supervision as necessary to meet the children's needs. 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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Site supervisor Claudia Avalos stated that during the next all staff meeting on 02/23/24, the facility will cover in detail the topics of care and supervsion, communication amongst staff, and working with children with special needs. The site supervisor will also submit the staff sign in sheet along with the meeting agenda and a written plan detailing how it intends to provide care and supervision as necessary to meet the children's needs and ensure that no child(ren) are left without the supervsion of a teacher at any time.
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Based on the LPA's interviews with facility staff S1-S5, adults A1 and A2, and the Unusual Incident Report submitted by the center on 01/29/24, child C1 eloped from the facility on 01/24/24 and was without staff supervision for up to five minutes while outside of the facility. This posed an immediate health and safety risk to the child in care.
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The site supervisor shall submit the above mentioned documents to the case carrying LPA by close of business 02/26/24.

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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:Yang Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024


LIC809 (FAS) - (06/04)
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