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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 493010083
Report Date: 06/13/2024
Date Signed: 06/13/2024 12:42:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/19/2024 and conducted by Evaluator Amy Strother
PUBLIC
COMPLAINT CONTROL NUMBER: 01-CC-20240319141342
FACILITY NAME:ACHIEVERSFACILITY NUMBER:
493010083
ADMINISTRATOR:HEATHER PETERSFACILITY TYPE:
850
ADDRESS:573 SUMMERFIELD ROADTELEPHONE:
(707) 539-6232
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:90CENSUS: 38DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Heather PetersTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not following the terms of their license
Facility was out of ratio
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Amy Strother made a subsequent complaint investigation inspection, for the purpose of delivering complaint findings, and met with Center Director, Heather Peters. It has been alleged that staff are not following the terms of their license, specifically that children who were not enrolled or are older than the limitations specified on the license were present and commingling with the children enrolled at the facility. It has also been alleged that the facility was out of ratio, specifically that during the week of 03/11/24 the outdoor area was not staffed with enough teachers when a teacher went inside.

During the initial investigation inspection on 03/20/24 LPA Strother toured the facility, made observations, received a current rooster of children in care and conducted interviews with Center Director (D1) and 2 staff (S1&S2). During the investigation, LPA Strother interviewed one additional staff (S6) and three adults (A1-A3) on 06/11/24 & 06/12/24. LPA received and reviewed additional documents from the facility on 06/11/24.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 01-CC-20240319141342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ACHIEVERS
FACILITY NUMBER: 493010083
VISIT DATE: 06/13/2024
NARRATIVE
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All staff interviewed confirmed that some staff’s children do at times come to the facility after school. The name’s of the staff’s children, all identified as school age, included C1 – C4. Most of the staff interviewed stated that they believed that child (C1) was enrolled at the facility and eligible to attend. LPA’s review of the facility roster proved that child C1 was not listed on the roster. During an additional interview with D1 on 06/11/24, D1 told LPA Strother that C1 was disenrolled from the program when C1 entered kindergarten in August of 2023, but thought that C1 was still eligible to be present within the terms of the license. Staff’s accounts of C2-C4’s presence at the facility varied, however more than one staff admitted that they have observed C2 and C4 on the playground interacting with the enrolled children on multiple occasions. Two of the three adults interviewed stated that they have witnessed C1 or a staff’s child that appears to be 6 years old in attendance on more than one occasion. One adult interviewed stated that she has observed children C1, C2 and C4 playing on the playground with the enrolled children. Based on record review and interviews with staff and adults it has been corroborated that the facility has operated outside the terms of the license.

All staff interviewed denied the allegation that the facility has operated out of ratio, giving examples of always counting and knowing how many children they have and how many staff are needed. Some staff interviewed stated that they will bring children inside with them as a means of remaining in ratio outside, stating the following example: “If we have 30 children outside with three teachers and one teacher needs to go inside, that teacher will bring 6 children inside with them.” The adults interviewed were not aware of the specific ratio requirements but stated that they did not have concerns about the supervision and feel that there has always been enough staff present with the children. Two of the three adults interviewed stated that they have witnessed staff counting the children or marking a board with the number of children, and changing the number when a child goes home. Although none of the interviews conducted corroborated the allegation that the facility operated out of ratio, based on LPA’s observation the facility was out of ratio during nap time on 03/20/24. When LPA arrived at the facility at 1:50pm it was nap time. S1 was observed in the Butterflies classroom with 23 children present and S2 and S3 were in the Busy Bee classroom with 13 children. At 2:05pm LPA witnessed a parent arrive to pick up their child from the Butterflies. S1 told the parent, “He didn’t sleep today.” At 2:35pm LPA witnessed several children now awake on their nap mats. LPA asked S1 if there was a qualified staff available to come into the classroom to meet the ratio requirements. S1 stated that she thought that if the children were on their mats she was within ratio. LPA explained that the children must be sleeping for the ratio of 24 to 1 teacher to apply, with a qualified staff on site and available to step in when a child wakes.
Continue on LIC809-C
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 01-CC-20240319141342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ACHIEVERS
FACILITY NUMBER: 493010083
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2024
Section Cited
CCR
101161(a)
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101161 Limitations on Capacity (a) A licensee shall not operate a child care center beyond the conditions and limitations specified on the license, including the capacity limitation.


This requirement was not met as evidenced by:
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Director, Heather Peters stated that she will submit a written statement about the facilities policy regarding children of staff by 06/27/24.
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Based on interviews conducted children C1, C2 & C4 have been observed playing on the playground with the children enrolled on more than one occasion and are not enrolled at the facility or do not meet the limitations specified on the license, which poses a potential health, safety and/or personal rights risk to the children in care.
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Type B
06/27/2024
Section Cited
CCR
101230(c)
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101230 Activities (c) A teacher-child ratio of one teacher supervising 24 napping children is permitted provided that the remaining teachers necessary to meet the overall ratio specified in Section 101216.3(a) are immediately available at the center.

This requirement was not met as evidenced by:
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Director Heather Peters stated that she will provide a written statement regarding her understanding of the teacher ratios during nap time and when the available staff must step in to meet the requirements by 06/27/24.
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Based on LPA’s observation and interview, on 03/20/24 at 2:05pm, S1 was supervising 23 children in the Butterflies nap room, with more than one child awake on their nap mats without a teacher immediately available at the center to join S1 to meet the ratio requirements, which poses a potential health, safety and/or personal rights risk to the children in care.
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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.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 01-CC-20240319141342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA CC RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ACHIEVERS
FACILITY NUMBER: 493010083
VISIT DATE: 06/13/2024
NARRATIVE
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S1 stated that Director (D1) was out on their lunch break, S4 had gone home as scheduled at 2:00pm and that S5 could come in from the kitchen, but does not have the qualifications of a teacher. Based on LPA's observation and interview with S1, the facility did not meet the ratio requirements during nap time on 03/20/24.

Based on LPA observations, records reviewed and interviews conducted, the preponderance of evidence standard has been met; therefore, the above allegations were found to be SUBSTANTIATED. California Code of Regulations, Title 22 is cited on the attached LIC9099-D.

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. Appeal Rights were provided and this report reviewed with facility representative, Heather Peters.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Amy Strother
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4