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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008727
Report Date: 10/18/2024
Date Signed: 10/18/2024 03:55:04 PM

Document Has Been Signed on 10/18/2024 03:55 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: 29CENSUS: 19DATE:
10/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:28 PM
MET WITH:Arlene Corazon Rivera, Site SupervisorTIME VISIT/
INSPECTION COMPLETED:
04:14 PM
NARRATIVE
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A case management visit to the facility was made today by Licensing Program Analyst (LPA) Y. Yang in response to a self-reported lack of supervision incident that occurred at the facility on 10/10/24. During today’s visit, the LPA met with the site supervisor, Arlene Corazon Rivera to discuss the details of this incident and provide technical assistance and best practice recommendations.

Based on the incident report submitted by the facility, it was reported that on 10/10/24 at approximately 10:19am, child C1 was left on the facility’s fully fenced play yard without staff supervision for approximately two minutes during an outdoor to indoor transition. The facility reported that C1 was found by staff S1, who was transitioning her classroom of toddler children to the play yard. The facility reported that S1 observed C1 by the door to the preschool classroom and escorted C1 back to their classroom. The facility reported that C1 did not appear to be in distress.

The facility reported that C1’s authorized representative was notified of this incident. This incident was self-reported by the facility on 10/10/24 and a written Unusual Incident Report (UIR) was received by the Department on 10/17/24. The facility reported that an internal investigation was conducted and staff present that day were interviewed. The facility reported that the investigation found that the name to face transition procedure was not followed by staff members.

California Code of Regulations, Title 22 is being cited on the attached LIC 809-D. The exit interview was conducted, and this report was read and discussed with the site supervisor, Arlene Corazon Rivera. Appeal rights were provided. The Notice of Site Visit shall be posted for 30 days.

This is a repeat violation of a similar incident that occurred at the facility on 01/24/24. No civil penalty is being assessed as this is a Title 5 funded facility. 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: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/18/2024 03:55 PM - It Cannot Be Edited


Created By: Yang Yang On 10/18/2024 at 02:00 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: 10/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2024
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:

Based on the LPA's interviews with facility staff and the Unusual Incident Report submitted by the center on 10/17/24, child C1 was without staff supervision for up to two minutes while on the preschool's fully fenced playground. This posed a potential health and safety risk to the child in care.
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Site supervisor, Arlene Corazon Rivera stated that the facility will be implementing a new name to face transition procedure that includes the use of a "transition tracking sheet." Additionally, the center will submit a written plan to the LPA documenting how it will follow care and supervision regulations and prevent a similar incident from occurring again. The plan of correction shall be submitted to the LPA by 10/21/24.

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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: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
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