401710988-3-9-2023-17-CC-FVEZ-CPS74V-20230309202035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 401710988
Report Date: 03/09/2023
Date Signed: 03/09/2023 08:20:49 PM

Document Has Been Signed on 03/09/2023 08:20 PM - It Cannot Be Edited

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 START		FACILITY NUMBER:	401710988
ADMINISTRATOR:	A. RAMIREZ-BARRON		FACILITY TYPE:	850
ADDRESS:	1800 WILMAR STREET		TELEPHONE:	(805) 473-1657
CITY:	OCEANO	STATE: CA	ZIP CODE:	93445
CAPACITY:	43	CENSUS: 4	DATE:	03/09/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Bobbie Sesena		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/9/23 at 2:00 PM, Licensing Program Analyst (LPA) Francisca Velazquez conducted a Case Management inspection at the Child Care Center (CCC), for the purpose of following up on the report of an Unusual Incident Report (UIR) received by the Department on 3/3/23. Specifically, the incident involved a child in care, C1, exited the classroom and walked outside to an outdoor play structure. LPA met with Area Manager, Bobbie Sesena and discuss the purpose of today's inspection. LPA notes four (4) children were present during inspection. Area Manager informed LPA, C1 exit the classroom and walked outside to an outdoor play structure. CCC conducted staff interviews and found that C1 came inside the CCC with the group of children to transition from outdoor play to lunch time. C1 did not want to sit for lunch and proceed to walk away from the table and eventually out of the classroom. CCC reports C1 was redirected to come back into the center and upon entering proceeded to sit at the table to have lunch. CCC reports, C1 has no prolonged effects related to the incident. Area Manager contacted parent to reported incident that occurred. Parent reported that C1 was fine and had not mentioned anything about the incident. C1 continues to be enrolled in the facility and parents have not expressed terminating services. LPA and Area Manager discussed active supervision. Area Manager reported CCC has conducted investigation and made proper updates to the CCC to ensure this incident does not occur again. The CCC has added chimes on the door leading to the outdoor play area that ring loud when CCC door is open. The CCC also has a safety gate on the door that leads to the outdoor play area for additional security. In addition, CCC has made changes to the staffing in the CCC to ensure active supervision is always occurring. Lastly, CCC staff will be participating in an active supervision training being provided by CCC next week. LPA contacted the parent (P1) of C1, who provided an account of the incident. As noted, P1 describes C1 is well and continues to be enrolled in the CCC. CONT 809-C

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca Velazquez	TELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 - FIVE CITIES HEAD START	FACILITY NUMBER: 401710988
	VISIT DATE: 03/09/2023

NARRATIVE

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Following the incident C1 continues to be enrolled in the CCC. Although C1 was able to exit the classroom and walk outside to the outdoor play structure the outdoor area is fully enclosed. CCC made immediate changes in the building and with staffing to ensure active supervision is always happening.

During today’s inspection technical assistance was provided regarding active care and supervision.

Exit interview and review of report was conducted with Area Manager, Bobbie Sesena. Notice of Site visit was provided and must remain posted for the next 30 days.

SUPERVISOR'S NAME: Maria Mueller	TELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca Velazquez	TELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC809 (FAS) - (06/04)

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