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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 401700014
Report Date: 09/05/2019
Date Signed: 09/06/2019 08:51:19 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2019 and conducted by Evaluator Gigi Reyes
PUBLIC
COMPLAINT CONTROL NUMBER: 17-CC-20190903165911
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: 16DATE:
09/05/2019
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Karen EastonTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Child inappropriately disenrolled
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gigi Reyes conducted an unannouced inspection to initiate the complaint allegation received on 9/3/2019. LPA met withCenter Direcctor, Ms. Karen Easton. There were 16 children present.
Regarding the allegation Child # 1 was inappropriately disenrolled, based on the interview conducted and record review Child #1 started on 8/19/19 and Child # 1's last day was 8/29/2019. On the same day, Authorized representative/Guardian of Child # 1 was informed by the Driector that CAPSLO Medical Exemption Form needs to be filled out prior to returning to school. Representative/Guardian of Child # 1 provided a Medical Exemption letter from a licensed phycisian and was told by the Center Director, it did not satisfy the immunization requirement because the letter did not state the health reason for exemption.

Based on LPAs observation, interviews conducted and record review, the preponderance of evidence standard has been met, there for the above allegation( is found SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number) or Health and Safety Code are being cited on the attached LIC 9099D.
Appeal Rights Given. Notice of Site Visit was posted.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 17-CC-20190903165911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 START
FACILITY NUMBER: 401700014
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/13/2019
Section Cited
CCR
101219(b)(7)
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(b) Admission agreements shall specify the following:
(7) Conditions under which the agreement may be terminated.

This requirement is not met as evidenced by: Based on the interview conducted, Child # 1's last day was 8/29/2019 because guardian failed to submit the CAPSLO Medical Exemption for Immunization form
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Director will review the Admission Agreement and submit plan of correction letter by 9/13/2019.
Director will contact the authorized representative of Child # 1 to bring the child back to school.
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The medical exemption letter from a licensed medical doctor was not honored by the school because it did not indicate the health reason. Center director stated Child # 1 was not disenrolled, it was a center requirement to have that Medical Exemption form filled out. This poses a potential risk to health and safety of 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.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019
LIC9099 (FAS) - (06/04)
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