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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 574500624
Report Date: 06/07/2024
Date Signed: 06/07/2024 03:33:58 PM

Document Has Been Signed on 06/07/2024 03:33 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WOODLAND HAVEN PRESCHOOLFACILITY NUMBER:
574500624
ADMINISTRATOR/
DIRECTOR:		ASHLEY TOBURENFACILITY TYPE:
850
ADDRESS:1730 COTTONWOOD STREETTELEPHONE:
(530) 312-6690
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY: 60TOTAL ENROLLED CHILDREN: 60CENSUS: 32DATE:
06/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:director, Ashley ToburenTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On June 7, 2024, Licensing Program Analyst (LPA) Lauren Scott met with Director, Ashley Toburen for the purpose of an unannounced Case Management inspection.

On June 4, 2024, facility contacted CCLD regarding an Unusual Incident Report (UIR) that stated on June 3, 2024, two staff were supervising 7 children outside. While one staff was at the bathroom with one child, the other staff transitioned inside with the other children. Once both staff were inside, a parent alerted the staff one child was outside alone. LPA conducted interviews with staff that were present during the incident.

The facility reported the UIR to Community Care Licensing within 24hrs and were reminded to submit a written UIR was submitted within 7 days.

Based on the interviews and information obtained, one Title 22 Deficiency has been issued on the attached LIC 809-D. The facility was informed that this report dated 6/7/2024 documents one Type A citation which shall be posted for 30 consecutive days. The facility shall also provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Facility has been provided with appeal rights.

Exit interview conducted and report was reviewed with director, Ashley Toburen. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Chayntel Hunter
LICENSING EVALUATOR NAME: Lauren Scott
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2024
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 06/07/2024 03:33 PM - It Cannot Be Edited


Created By: Lauren Scott On 06/07/2024 at 03:10 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WOODLAND HAVEN PRESCHOOL
FACILITY NUMBER: 574500624

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/10/2024
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision... (1) No child(ren) shall be left without the supervision of a teacher at any time...Supervision shall include visual observation. This requirement was not met as evidenced by:
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Facility has conducted face to name trainings refresher for all staff. Signed meeting notes were reviewed. Facility is using app to conduct face to name during transitions

CIVIL PENALTIES WERE ASSESSED
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Based on interviews, the facility did not comply with the section cited above where one child was left outside alone, while the others were inside the classroom. This poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:Chayntel Hunter
LICENSING EVALUATOR NAME:Lauren Scott
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024


LIC809 (FAS) - (06/04)
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