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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008727
Report Date: 08/05/2024
Date Signed: 08/05/2024 12:22:30 PM

Document Has Been Signed on 08/05/2024 12:22 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/
DIRECTOR:
COPELAND, JENNYFACILITY TYPE:
850
ADDRESS:1455 GOLF COURSE DRIVETELEPHONE:
(707) 586-1253
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 71TOTAL ENROLLED CHILDREN: 24CENSUS: 17DATE:
08/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:36 AM
MET WITH:Claudia Avalos, Site SupervisorTIME VISIT/
INSPECTION COMPLETED:
11:22 AM
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An unannounced, follow-up case management visit to the facility was made today by Licensing Program Analyst (LPA) Y. Yang in response to a self reported, alleged personal rights violation incident at the facility on 07/15/24. Previously, case management visits were made to this facility on 07/24/24 and 07/31/24 to interview staff (S1-S5) and make observations. During today’s visit, the LPA met with the site supervisor, Claudia Avalos to discuss the reported incident.

Based on the Unusual Incident Report (UIR) received by the Department on 07/19/24, it was reported by the facility that on 07/15/24, child C1 reported to a staff member (staff S4) that staff S2 hit them on the right side of their buttocks. Site Supervisor Avalos stated that she interviewed C1 and examined the child's body for marks and injuries. Site Supervisor Avalos stated that she did not observe any marks or injuries on C1's body other than a round, "dime sized" mark on the child's buttock. Site Supervisor Avalos stated that the facility conducted its own internal investigation and found the allegation to be unsubstantiated. Site Supervisor Avalos reported that child C1's authorized representative was notified on the day of the allegation.

Based on available information, interviews conducted, and the LPA’s observations, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated at this time. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the site supervisor, Claudia Avalos. There were no Title 22 deficiencies cited during today's inspection.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Yang Yang
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2024
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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