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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 401700014
Report Date: 01/14/2020
Date Signed: 01/14/2020 12:51:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME:CAPSLO - ATASCADERO HEAD STARTFACILITY NUMBER:
401700014
ADMINISTRATOR:D. WELCH /K. EASTONFACILITY TYPE:
850
ADDRESS:965 EL CAMINO REALTELEPHONE:
(805) 466-0417
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:40CENSUS: DATE:
01/14/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Susan RiojasTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Case Management Inspection and met with Site Supervisor Susan Riojas. The purpose of the visit was discussed. There were 32 children and 8 teachers present including 2 Site Supervisors.

An incident occurred on 12/11/2019, about 10:45 AM at Bldg B - Extended Day Care. Child # 1 tripped and fell while running on the playground. During today's inspection, 1/14/2020, 11:15 AM LPA interviewed Staff # 1 who was present during the incident. Interview with Staff # 1 revealed that Child # 1 was running around a play structure when Child # 1 tripped and fell on the ground. LPA observed that the ground is cushioned with wooden chips. Staff # 1 stated Child # 1 fell face down, that there was no solid object that was on the ground to cause the bleeding. Site Supervisor stated Child # 1 must have bit the lip and the impact caused the lip and front teeth to bleed. Site Supervisor applied ice pack and the parent was called simultaneously. Parent came to pick up the child at 11:45 AM on the day of the incident. Child # 1 was brought to the Dentist. Dentist reported a mild lip contusion and there was no diet and activity restriction. Child # 1 came back to school on 12/12/2019. During the incident, there were 19 children and 4 staff present on the play ground.

No deficiencies were cited during the Case Management Inspection
LPA observed Site Supervisor posted Notice of Site Visit,
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 01/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2020
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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