IVEY RANCH PARK DAY CARE/RESPITE CTR. SCHOOL AGE

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Keely Messerschmidt and Licensing Program Manager (LPM) Debbie Mullen arrived at the facility on a case management inspection to observe changes made in the facility in relation to a capacity change. In addition, LPA issued a citation based upon information discovered during investigation on complaint #20240911134232. During the investigation on 9/18/24 LPA discovered that an incident in which Child #1 (C1) was injured and sought medical care was not reported to Community Care Licensing (CCL). An exit interview was conducted and a copy of this report was provided. Notice of site visit was provided and must remain posted for 30 days. Appeal Right were discussed and provided to Care Programs Manager Christina Paad. SUPERVISORS NAME: Deborah Mullen LICENSING EVALUATOR NAME: Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025 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 2 FACILITY NAME: IVEY RANCH PARK DAY CARE/RESPITE CTR. SCHOOL AGE FACILITY NUMBER: 372006026 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 02/13/2025 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/14/2025 Section Cited CCR 101212(d)(1)(B) 1 2 3 4 5 6 7(d) Upon the occurrence, during the operation of the child care center of any of the events specified in...(1)Events reported shall include the following:(B)Any injury to any child that requires medical treatment. This requirement was not met as evidenced by,1 2 3 4 5 6 7Care Programs Manager stated they will submit an Unusual Incident Report (UIR) for incident that took place with C1 and will continue to comply with regulations pertaining to reporting requirements. 8 9 10 11 12 13 14Based on interview, it was disclosed to LPA that a UIR was not completed for C1 injury which required parent to seek medical treatment. This is a potential risk to the health and safety of children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Deborah Mullen LICENSING EVALUATOR NAME:Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Keely Messerschmidt and Licensing Program Manager (LPM) Debbie Mullen arrived at the facility on a case management inspection to observe changes made in the facility in relation to a capacity change. In addition, LPA issued a citation based upon information discovered during investigation on complaint #20240911134232. During the investigation on 9/18/24 LPA discovered that an incident in which Child #1 (C1) was injured and sought medical care was not reported to Community Care Licensing (CCL). An exit interview was conducted and a copy of this report was provided. Notice of site visit was provided and must remain posted for 30 days. Appeal Right were discussed and provided to Care Programs Manager Christina Paad. SUPERVISORS NAME: Deborah Mullen LICENSING EVALUATOR NAME: Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025 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 2 FACILITY NAME: IVEY RANCH PARK DAY CARE/RESPITE CTR. SCHOOL AGE FACILITY NUMBER: 372006026 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 02/13/2025 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/14/2025 Section Cited CCR 101212(d)(1)(B) 1 2 3 4 5 6 7(d) Upon the occurrence, during the operation of the child care center of any of the events specified in...(1)Events reported shall include the following:(B)Any injury to any child that requires medical treatment. This requirement was not met as evidenced by,1 2 3 4 5 6 7Care Programs Manager stated they will submit an Unusual Incident Report (UIR) for incident that took place with C1 and will continue to comply with regulations pertaining to reporting requirements. 8 9 10 11 12 13 14Based on interview, it was disclosed to LPA that a UIR was not completed for C1 injury which required parent to seek medical treatment. This is a potential risk to the health and safety of children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Deborah Mullen LICENSING EVALUATOR NAME:Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Keely Messerschmidt and Licensing Program Manager (LPM) Debbie Mullen arrived at the facility on a case management inspection to observe changes made in the facility in relation to a capacity change. In addition, LPA issued a citation based upon information discovered during investigation on complaint #20240911134232. During the investigation on 9/18/24 LPA discovered that an incident in which Child #1 (C1) was injured and sought medical care was not reported to Community Care Licensing (CCL). An exit interview was conducted and a copy of this report was provided. Notice of site visit was provided and must remain posted for 30 days. Appeal Right were discussed and provided to Care Programs Manager Christina Paad. SUPERVISORS NAME: Deborah Mullen LICENSING EVALUATOR NAME: Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025 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 2 FACILITY NAME: IVEY RANCH PARK DAY CARE/RESPITE CTR. SCHOOL AGE FACILITY NUMBER: 372006026 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 02/13/2025 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/14/2025 Section Cited CCR 101212(d)(1)(B) 1 2 3 4 5 6 7(d) Upon the occurrence, during the operation of the child care center of any of the events specified in...(1)Events reported shall include the following:(B)Any injury to any child that requires medical treatment. This requirement was not met as evidenced by,1 2 3 4 5 6 7Care Programs Manager stated they will submit an Unusual Incident Report (UIR) for incident that took place with C1 and will continue to comply with regulations pertaining to reporting requirements. 8 9 10 11 12 13 14Based on interview, it was disclosed to LPA that a UIR was not completed for C1 injury which required parent to seek medical treatment. This is a potential risk to the health and safety of children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Deborah Mullen LICENSING EVALUATOR NAME:Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Keely Messerschmidt and Licensing Program Manager (LPM) Debbie Mullen arrived at the facility on a case management inspection to observe changes made in the facility in relation to a capacity change. In addition, LPA issued a citation based upon information discovered during investigation on complaint #20240911134232. During the investigation on 9/18/24 LPA discovered that an incident in which Child #1 (C1) was injured and sought medical care was not reported to Community Care Licensing (CCL). An exit interview was conducted and a copy of this report was provided. Notice of site visit was provided and must remain posted for 30 days. Appeal Right were discussed and provided to Care Programs Manager Christina Paad. SUPERVISORS NAME: Deborah Mullen LICENSING EVALUATOR NAME: Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025 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 2 FACILITY NAME: IVEY RANCH PARK DAY CARE/RESPITE CTR. SCHOOL AGE FACILITY NUMBER: 372006026 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 02/13/2025 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/14/2025 Section Cited CCR 101212(d)(1)(B) 1 2 3 4 5 6 7(d) Upon the occurrence, during the operation of the child care center of any of the events specified in...(1)Events reported shall include the following:(B)Any injury to any child that requires medical treatment. This requirement was not met as evidenced by,1 2 3 4 5 6 7Care Programs Manager stated they will submit an Unusual Incident Report (UIR) for incident that took place with C1 and will continue to comply with regulations pertaining to reporting requirements. 8 9 10 11 12 13 14Based on interview, it was disclosed to LPA that a UIR was not completed for C1 injury which required parent to seek medical treatment. This is a potential risk to the health and safety of children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Deborah Mullen LICENSING EVALUATOR NAME:Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025

Type B citation - potential risk if not corrected

Type B citation - potential risk if not corrected

Type B citation - potential risk if not corrected

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 25Licensing Program Analyst (LPA) Keely Messerschmidt and Licensing Program Manager (LPM) Debbie Mullen arrived at the facility on a case management inspection to observe changes made in the facility in relation to a capacity change. In addition, LPA issued a citation based upon information discovered during investigation on complaint #20240911134232. During the investigation on 9/18/24 LPA discovered that an incident in which Child #1 (C1) was injured and sought medical care was not reported to Community Care Licensing (CCL). An exit interview was conducted and a copy of this report was provided. Notice of site visit was provided and must remain posted for 30 days. Appeal Right were discussed and provided to Care Programs Manager Christina Paad. SUPERVISORS NAME: Deborah Mullen LICENSING EVALUATOR NAME: Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025 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 2 FACILITY NAME: IVEY RANCH PARK DAY CARE/RESPITE CTR. SCHOOL AGE FACILITY NUMBER: 372006026 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 02/13/2025 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/14/2025 Section Cited CCR 101212(d)(1)(B) 1 2 3 4 5 6 7(d) Upon the occurrence, during the operation of the child care center of any of the events specified in...(1)Events reported shall include the following:(B)Any injury to any child that requires medical treatment. This requirement was not met as evidenced by,1 2 3 4 5 6 7Care Programs Manager stated they will submit an Unusual Incident Report (UIR) for incident that took place with C1 and will continue to comply with regulations pertaining to reporting requirements. 8 9 10 11 12 13 14Based on interview, it was disclosed to LPA that a UIR was not completed for C1 injury which required parent to seek medical treatment. This is a potential risk to the health and safety of children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Deborah Mullen LICENSING EVALUATOR NAME:Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Keely Messerschmidt and Licensing Program Manager (LPM) Debbie Mullen arrived at the facility on a case management inspection to observe changes made in the facility in relation to a capacity change. In addition, LPA issued a citation based upon information discovered during investigation on complaint #20240911134232. During the investigation on 9/18/24 LPA discovered that an incident in which Child #1 (C1) was injured and sought medical care was not reported to Community Care Licensing (CCL). An exit interview was conducted and a copy of this report was provided. Notice of site visit was provided and must remain posted for 30 days. Appeal Right were discussed and provided to Care Programs Manager Christina Paad. SUPERVISORS NAME: Deborah Mullen LICENSING EVALUATOR NAME: Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025 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 2 FACILITY NAME: IVEY RANCH PARK DAY CARE/RESPITE CTR. SCHOOL AGE FACILITY NUMBER: 372006026 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 02/13/2025 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/14/2025 Section Cited CCR 101212(d)(1)(B) 1 2 3 4 5 6 7(d) Upon the occurrence, during the operation of the child care center of any of the events specified in...(1)Events reported shall include the following:(B)Any injury to any child that requires medical treatment. This requirement was not met as evidenced by,1 2 3 4 5 6 7Care Programs Manager stated they will submit an Unusual Incident Report (UIR) for incident that took place with C1 and will continue to comply with regulations pertaining to reporting requirements. 8 9 10 11 12 13 14Based on interview, it was disclosed to LPA that a UIR was not completed for C1 injury which required parent to seek medical treatment. This is a potential risk to the health and safety of children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Deborah Mullen LICENSING EVALUATOR NAME:Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Keely Messerschmidt and Licensing Program Manager (LPM) Debbie Mullen arrived at the facility on a case management inspection to observe changes made in the facility in relation to a capacity change. In addition, LPA issued a citation based upon information discovered during investigation on complaint #20240911134232. During the investigation on 9/18/24 LPA discovered that an incident in which Child #1 (C1) was injured and sought medical care was not reported to Community Care Licensing (CCL). An exit interview was conducted and a copy of this report was provided. Notice of site visit was provided and must remain posted for 30 days. Appeal Right were discussed and provided to Care Programs Manager Christina Paad. SUPERVISORS NAME: Deborah Mullen LICENSING EVALUATOR NAME: Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025 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 2 FACILITY NAME: IVEY RANCH PARK DAY CARE/RESPITE CTR. SCHOOL AGE FACILITY NUMBER: 372006026 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 02/13/2025 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/14/2025 Section Cited CCR 101212(d)(1)(B) 1 2 3 4 5 6 7(d) Upon the occurrence, during the operation of the child care center of any of the events specified in...(1)Events reported shall include the following:(B)Any injury to any child that requires medical treatment. This requirement was not met as evidenced by,1 2 3 4 5 6 7Care Programs Manager stated they will submit an Unusual Incident Report (UIR) for incident that took place with C1 and will continue to comply with regulations pertaining to reporting requirements. 8 9 10 11 12 13 14Based on interview, it was disclosed to LPA that a UIR was not completed for C1 injury which required parent to seek medical treatment. This is a potential risk to the health and safety of children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Deborah Mullen LICENSING EVALUATOR NAME:Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Keely Messerschmidt and Licensing Program Manager (LPM) Debbie Mullen arrived at the facility on a case management inspection to observe changes made in the facility in relation to a capacity change. In addition, LPA issued a citation based upon information discovered during investigation on complaint #20240911134232. During the investigation on 9/18/24 LPA discovered that an incident in which Child #1 (C1) was injured and sought medical care was not reported to Community Care Licensing (CCL). An exit interview was conducted and a copy of this report was provided. Notice of site visit was provided and must remain posted for 30 days. Appeal Right were discussed and provided to Care Programs Manager Christina Paad. SUPERVISORS NAME: Deborah Mullen LICENSING EVALUATOR NAME: Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025 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 2 FACILITY NAME: IVEY RANCH PARK DAY CARE/RESPITE CTR. SCHOOL AGE FACILITY NUMBER: 372006026 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 02/13/2025 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/14/2025 Section Cited CCR 101212(d)(1)(B) 1 2 3 4 5 6 7(d) Upon the occurrence, during the operation of the child care center of any of the events specified in...(1)Events reported shall include the following:(B)Any injury to any child that requires medical treatment. This requirement was not met as evidenced by,1 2 3 4 5 6 7Care Programs Manager stated they will submit an Unusual Incident Report (UIR) for incident that took place with C1 and will continue to comply with regulations pertaining to reporting requirements. 8 9 10 11 12 13 14Based on interview, it was disclosed to LPA that a UIR was not completed for C1 injury which required parent to seek medical treatment. This is a potential risk to the health and safety of children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Deborah Mullen LICENSING EVALUATOR NAME:Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Keely Messerschmidt and Licensing Program Manager (LPM) Debbie Mullen arrived at the facility on a case management inspection to observe changes made in the facility in relation to a capacity change. In addition, LPA issued a citation based upon information discovered during investigation on complaint #20240911134232. During the investigation on 9/18/24 LPA discovered that an incident in which Child #1 (C1) was injured and sought medical care was not reported to Community Care Licensing (CCL). An exit interview was conducted and a copy of this report was provided. Notice of site visit was provided and must remain posted for 30 days. Appeal Right were discussed and provided to Care Programs Manager Christina Paad. SUPERVISORS NAME: Deborah Mullen LICENSING EVALUATOR NAME: Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025 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 2 FACILITY NAME: IVEY RANCH PARK DAY CARE/RESPITE CTR. SCHOOL AGE FACILITY NUMBER: 372006026 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 02/13/2025 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/14/2025 Section Cited CCR 101212(d)(1)(B) 1 2 3 4 5 6 7(d) Upon the occurrence, during the operation of the child care center of any of the events specified in...(1)Events reported shall include the following:(B)Any injury to any child that requires medical treatment. This requirement was not met as evidenced by,1 2 3 4 5 6 7Care Programs Manager stated they will submit an Unusual Incident Report (UIR) for incident that took place with C1 and will continue to comply with regulations pertaining to reporting requirements. 8 9 10 11 12 13 14Based on interview, it was disclosed to LPA that a UIR was not completed for C1 injury which required parent to seek medical treatment. This is a potential risk to the health and safety of children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Deborah Mullen LICENSING EVALUATOR NAME:Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25Licensing Program Analyst (LPA) Keely Messerschmidt and Licensing Program Manager (LPM) Debbie Mullen arrived at the facility on a case management inspection to observe changes made in the facility in relation to a capacity change. In addition, LPA issued a citation based upon information discovered during investigation on complaint #20240911134232. During the investigation on 9/18/24 LPA discovered that an incident in which Child #1 (C1) was injured and sought medical care was not reported to Community Care Licensing (CCL). An exit interview was conducted and a copy of this report was provided. Notice of site visit was provided and must remain posted for 30 days. Appeal Right were discussed and provided to Care Programs Manager Christina Paad. SUPERVISORS NAME: Deborah Mullen LICENSING EVALUATOR NAME: Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025 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 2 FACILITY NAME: IVEY RANCH PARK DAY CARE/RESPITE CTR. SCHOOL AGE FACILITY NUMBER: 372006026 DEFICIENCY INFORMATION FOR THIS PAGE: VISIT DATE: 02/13/2025 Deficiency Type POC Due Date / Section NumberDEFICIENCIESPLAN OF CORRECTIONS(POCs) Type B 02/14/2025 Section Cited CCR 101212(d)(1)(B) 1 2 3 4 5 6 7(d) Upon the occurrence, during the operation of the child care center of any of the events specified in...(1)Events reported shall include the following:(B)Any injury to any child that requires medical treatment. This requirement was not met as evidenced by,1 2 3 4 5 6 7Care Programs Manager stated they will submit an Unusual Incident Report (UIR) for incident that took place with C1 and will continue to comply with regulations pertaining to reporting requirements. 8 9 10 11 12 13 14Based on interview, it was disclosed to LPA that a UIR was not completed for C1 injury which required parent to seek medical treatment. This is a potential risk to the health and safety of children in care.8 9 10 11 12 13 14 1 2 3 4 5 6 71 2 3 4 5 6 7 1 2 3 4 5 6 71 2 3 4 5 6 7 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:Deborah Mullen LICENSING EVALUATOR NAME:Keely Messerschmidt LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025 I acknowledge receipt of this form and understand my appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025

Type B citation from complaint investigation - potential risk if not corrected