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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010083
Report Date: 05/01/2023
Date Signed: 05/01/2023 02:21:34 PM

Document Has Been Signed on 05/01/2023 02:21 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:ACHIEVERSFACILITY NUMBER:
493010083
ADMINISTRATOR:HEATHER PETERSFACILITY TYPE:
850
ADDRESS:573 SUMMERFIELD ROADTELEPHONE:
(707) 539-6232
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 90TOTAL ENROLLED CHILDREN: 63CENSUS: 35DATE:
05/01/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Heather PetersTIME COMPLETED:
02:30 PM
NARRATIVE
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An unannounced Case Management visit was made to the facility by Licensing Program Analyst (LPA) Amy Strother to address an incident that was brought to the attention of the Department by way of a complaint allegation: Staff do not adequately supervise children in care, compliant report 01-CC-20230203113758, dated 02/03/23. The compliant report specifically stated that approximately 2 weeks ago, Child 2 (C2) was left outside in the backyard unsupervised for 15 minutes, that the incident was captured on video footage. The reporting party stated that the Center Director (D1) was aware of the incident, but did not report it to Community Care Licensing (CCL) as required. LPA Strother viewed video footage from 01/17/23 observing C2 outside on the playground unsupervised for 17 minutes. LPA also reviewed records that indicate that D1 was aware of the incident and discussed the incident with staff on 01/17/23. D1 did not notify CCL of the incident with a phone call or submit an Unusual Incident Report (UIR) as required.

The following deficiency is being cited (see LIC 809D). Appeal Rights were provided.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the Director, Heather Peters.

SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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 05/01/2023 02:21 PM - It Cannot Be Edited


Created By: Amy Strother On 05/01/2023 at 01:10 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: ACHIEVERS
FACILITY NUMBER: 493010083

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/15/2023
Section Cited
CCR
101212(d)(1)(C)

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101212 ...during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by… next working day... In addition, a written report…shall be submitted to the Department within seven days...(1)Events reported shall include the following: (C)Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement was not met as evidenced by:
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Licensee and Director will watch the Child Care Center Reporting Requirements Video on CCLD’s website: https://ccld.childcarevideos.org/child-care-center-operators/child-care-reporting-requirements/ and then send to CCL the signatures declaring that the video as been viewed and a written procedure for how reporting will be handled in the future.
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Based on interview and record review D1 was aware of an incident on 1/17/23 where Child 2 (C2) was left outside unsupervised for 17 minutes and found by a parent passing by on the other side of the fence who alerted staff, but did not report it to the Department and did not submit a written incident report timely as required. This poses a potential health, safety or personal rights risk to persons in care.
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The signed document will be submitted to CCL by 5/15/23 to amy.strother@dss.ca.gov

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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:Amy Strother
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023


LIC809 (FAS) - (06/04)
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