KELSEYVILLE EARLY CONNECTION

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 10/13/2025, Licensing Program Analysts (LPA), Sebastian Phouthaovong made an unannounced Case Management visit in response to a self-reported Unusual Incident Report (UIR). UIR was notified to Community Care Licensing on 10/07/2025. The incident was regarding a child that left the facility's playground to another program's field. LPA met with Site Supervisor, Sajeanne Burgoyne and spoke with her the purpose of today's visit. During today's inspection, LPA toured the facility inside and out and observed 24 children being supervised by five staff members. LPA conducted interviews with the Site Supervisor, Assistant Site Supervisor and one staff member. Assistant Site Supervisor and one staff admitted that they lose supervision on the child, however the child was supervised by a school campus staff member during the child's absent. Furthermore, the child was immediately returned to the facility once facility staff were notified. Site Supervisor, Assistant Site Supervisor and staff also stated that the facility has taken preventative measures to ensure proper supervision, which was reviewed by LPA. 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 Site Supervisor, Sajeanne Burgoyne. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr NAME OF LICENSING PROGRAM ANALYST: Sebastian Phouthavong LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025 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 3 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

Type B citation - potential risk if not corrected

Type B citation - potential risk if not corrected

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 10/13/2025, Licensing Program Analysts (LPA), Sebastian Phouthaovong made an unannounced Case Management visit in response to a self-reported Unusual Incident Report (UIR). UIR was notified to Community Care Licensing on 10/07/2025. The incident was regarding a child that left the facility's playground to another program's field. LPA met with Site Supervisor, Sajeanne Burgoyne and spoke with her the purpose of today's visit. During today's inspection, LPA toured the facility inside and out and observed 24 children being supervised by five staff members. LPA conducted interviews with the Site Supervisor, Assistant Site Supervisor and one staff member. Assistant Site Supervisor and one staff admitted that they lose supervision on the child, however the child was supervised by a school campus staff member during the child's absent. Furthermore, the child was immediately returned to the facility once facility staff were notified. Site Supervisor, Assistant Site Supervisor and staff also stated that the facility has taken preventative measures to ensure proper supervision, which was reviewed by LPA. 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 Site Supervisor, Sajeanne Burgoyne. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr NAME OF LICENSING PROGRAM ANALYST: Sebastian Phouthavong LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025 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 3 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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 10/13/2025, Licensing Program Analysts (LPA), Sebastian Phouthaovong made an unannounced Case Management visit in response to a self-reported Unusual Incident Report (UIR). UIR was notified to Community Care Licensing on 10/07/2025. The incident was regarding a child that left the facility's playground to another program's field. LPA met with Site Supervisor, Sajeanne Burgoyne and spoke with her the purpose of today's visit. During today's inspection, LPA toured the facility inside and out and observed 24 children being supervised by five staff members. LPA conducted interviews with the Site Supervisor, Assistant Site Supervisor and one staff member. Assistant Site Supervisor and one staff admitted that they lose supervision on the child, however the child was supervised by a school campus staff member during the child's absent. Furthermore, the child was immediately returned to the facility once facility staff were notified. Site Supervisor, Assistant Site Supervisor and staff also stated that the facility has taken preventative measures to ensure proper supervision, which was reviewed by LPA. 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 Site Supervisor, Sajeanne Burgoyne. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr NAME OF LICENSING PROGRAM ANALYST: Sebastian Phouthavong LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025 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 3 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

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25On 10/13/2025, Licensing Program Analysts (LPA), Sebastian Phouthaovong made an unannounced Case Management visit in response to a self-reported Unusual Incident Report (UIR). UIR was notified to Community Care Licensing on 10/07/2025. The incident was regarding a child that left the facility's playground to another program's field. LPA met with Site Supervisor, Sajeanne Burgoyne and spoke with her the purpose of today's visit. During today's inspection, LPA toured the facility inside and out and observed 24 children being supervised by five staff members. LPA conducted interviews with the Site Supervisor, Assistant Site Supervisor and one staff member. Assistant Site Supervisor and one staff admitted that they lose supervision on the child, however the child was supervised by a school campus staff member during the child's absent. Furthermore, the child was immediately returned to the facility once facility staff were notified. Site Supervisor, Assistant Site Supervisor and staff also stated that the facility has taken preventative measures to ensure proper supervision, which was reviewed by LPA. 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 Site Supervisor, Sajeanne Burgoyne. The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. NAME OF LICENSING PROGRAM MANAGER: Melinda Mohr NAME OF LICENSING PROGRAM ANALYST: Sebastian Phouthavong LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2025 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 3 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