<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493008727
Report Date: 01/14/2025
Date Signed: 01/14/2025 04:24:10 PM

Document Has Been Signed on 01/14/2025 04:24 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: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: 33CENSUS: 11DATE:
01/14/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:38 PM
MET WITH:Arlene “Corazon” Rivera, Site SupervisorTIME VISIT/
INSPECTION COMPLETED:
04:09 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 12/20/2024 involving a child sustaining a head injury while in care. During today’s visit, the LPA met with the facility’s site supervisor, Arlene “Corazon” Rivera, to discuss the incident and obtain additional details. The site supervisor reported that on 12/17/24, child C1 was pushed by child C2 while playing on the play yard and lost their balance and hit the back of their head on a wooden step. The site supervisor reported that staff member S1 was standing in the vicinity and went to assist C1. The site supervisor reported that C1 was offered an ice pack several times but C1 refused. The site supervisor reported that C1’s authorized representative was notified and C1 was comforted while awaiting pick up by their authorized representative. The site supervisor stated that C1’s authorized representative transported C1 to be examined by a medical professional. The site supervisor stated that C1’s authorized representative notified her that C1 sustained a concussion because of the injury.

During today's case management visit, the LPA reviewed with the site supervisor the facility's child supervision policies. The LPA inspected the outdoor play area and observed that the wooden step that child C1 fell on was an age-appropriate, piece of childcare equipment from an outdoor obstacle set. The LPA also observed that there is sufficient wood chip cushioning material in this area even though there were no play structures present that require fall cushioning. 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, Arlene “Corazon” Rivera, Site Supervisor. 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: 01/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/14/2025
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 1