493008727-5-13-2025-01-CC-YYAG-DGN2C9-20250513171622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 493008727
Report Date: 05/13/2025
Date Signed: 05/13/2025 05:16:32 PM

Document Has Been Signed on 05/13/2025 05:16 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 PRESCHOOL		FACILITY NUMBER:	493008727
ADMINISTRATOR/ DIRECTOR:	COPELAND, JENNY		FACILITY TYPE:	850
ADDRESS:	1455 GOLF COURSE DRIVE		TELEPHONE:	(707) 586-1253
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY: 71	TOTAL ENROLLED CHILDREN: 59	CENSUS: 33	DATE:	05/13/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:06 PM
MET WITH:	Heather Peters, Site Supervisor		TIME VISIT/ INSPECTION COMPLETED:	04:22 PM

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An unannounced case management visit was made to the facility by Licensing Program Analyst (LPA) Y. Yang in response to a self-reported, lack of supervision incident involving child C1 and staff S1 that occurred at the facility on 04/08/25. During today’s visit, the LPA met with the site supervisor, Heather Peters to discuss the incident and obtain additional information. The site supervisor informed the LPA that she was not on site during this incident and learned of the details afterwards.

The facility representative reported that on 04/08/25 at approximately 05:00pm, staff S1 was supervising child C1 and engaging in an activity in the preschool classroom. The facility representative reported that all other children and staff from this classroom were outside on the play yard and S1 was alone in the classroom with C1. The facility representative reported that during this activity, S1 received information that led her to believe that an unauthorized person was on site and planning to enter the classroom. The facility representative reported that fearing for their safety, S1 walked through the adjoining door of the preschool classroom and into the two’s classroom to see if the unauthorized person was on the premises and inadvertently left C1 in the preschool classroom and shut the adjoining door behind her. The facility representative reported that after an unknown amount of time (interviews with staff S1-S4 estimate a duration anywhere between three-to-ten minutes), staff S2 walked into the preschool classroom and observed C1 sitting alone at a table still engaged in an activity. The facility representative reported that staff S1 returned to the preschool classroom around this time as well. Both S1 and S2 reported that C1 was not in distress when found.

The facility representative stated that C1’s authorized representative was notified of this incident the same day. This incident was also reported to Community Care Licensing as required per regulations.

Although it was corroborated that child C1 was left alone in the classroom for a period of time, there was not a preponderance of evidence to suggest that this was done intentionally or due to negligence. There were no Title 22 deficiencies cited during today’s inspection visit. A notice of site visit was given and must remain posted for 30 days. Technical assistance and best practice recommendations were provided by the LPA during today’s case management visit. This report was read and reviewed with the site supervisor, Heather Peters.

NAME OF LICENSING PROGRAM MANAGER: Melchisedeck Augustin
NAME OF LICENSING PROGRAM ANALYST: Yang Yang
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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