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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 401710988
Report Date: 09/17/2019
Date Signed: 09/17/2019 02:51:34 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 - FIVE CITIES HEAD STARTFACILITY NUMBER:
401710988
ADMINISTRATOR:D WELCH/ M OROZCOFACILITY TYPE:
850
ADDRESS:1800 WILMAR STREETTELEPHONE:
(805) 473-1657
CITY:OCEANOSTATE: CAZIP CODE:
93445
CAPACITY:43CENSUS: 28DATE:
09/17/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maria OrozcoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Case Management Inspection regarding the incident which occurred on 8/21/2019. The purpose of the visit was discussed with the Site Director, Ms. Maria Orozco. There were 28 children and 7 staff present.

Site Director reported on 8/21/2019 that on the same day, about 12:25 PM Child # 1 climbed the play structure and slid down the pole. Interview with Site Supervisor revealed that Child # 1 slid fast and sat on step of the pole. Child #1 did not complain after the incident, however it was observed by Site Director that Child #1 was walking slow. Child 1 was cleared by medical doctor to go back to school the following day, 8/22/19. There were 16 children and 3 teachers present during the incident. Site supervisor stated staff were advised to be extra watchful and stand by the pole when day care children are in the play structure. LPA observed that play structure is age appropriate for 2 to 5 years of age.

No deficiencies cited

LPA observed Site Director posted the Notice of Site Visit.

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

DATE: 09/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2019
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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