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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 401710988
Report Date: 10/06/2020
Date Signed: 10/20/2020 12:15:50 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: 15DATE:
10/06/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Maria OrozcoTIME COMPLETED:
03:30 PM
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On 10/6/2020, Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Case Management inspection regarding an incident which occurred on 9/25/2020. Due to COVID-19 and Department of Public Health's guidelines pertaining to social distancing, a tele-inspection via face time was conducted. LPA Reyes met with Site Supervisor, Maria Orozco. During the tele-inspection, LPA conducted a physical tour observing the classrooms A, B and the outdoor activity space.

It was reported to Community Care Licensing that on 9/25/2020 on or about 12:15 PM, Child # 1 was running in the playground, tripped and fell on top of Child # 1's right arm. Child # 1 sustained injury on Child # 1's right arm. C1 fractured the right arm and cast was placed.

LPA Reyes interviewed Staff 1 (S1) and Staff 2 (S2) who were present during the incident. In two separate interviews, S1 and S2 stated that on 9/25/2020 on or about 12:15 PM, Child # 1 was running while looking back at the teachers and friends when C1 fell forward on top of C1's right arm. Staff 1 picked up C1, applied first aide while Site Supervisor contacted the authorized representative of C1. C1's injury required a medical treatment of casting the right arm. C1 reported back to preschool on 9/28/2020.

Interview with Site supervisor and Staff 1 revealed that there were no holes in the playground. Site Supervisor stated that pre school playground is due for maintenance to ensure that the surface of outdoor activity space is free of any hazard.

During today's inspection, no deficiencies were cited.

Exit interview was conducted, Evaluation Report and Notice of Site Visit were issued.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020
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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