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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406206384
Report Date: 12/19/2019
Date Signed: 12/19/2019 01:24:36 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 - STEP BY STEP EARLY HEAD STARTFACILITY NUMBER:
406206384
ADMINISTRATOR:RUBY ALCANTARFACILITY TYPE:
830
ADDRESS:1055 MESA VIEW DRIVETELEPHONE:
(805) 474-3750
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:16CENSUS: 11DATE:
12/19/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Aurora HernandezTIME COMPLETED:
01:35 PM
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Licensing Program Analysts (LPA) Martina Jimenez conducted a Case Management - Incident visit and met with the family services advocate-- Aurora Hernandez, to follow up on an incident that was self-reported to the department on December 13, 2019. LPA observed during the visit 11 children and three staff present.

During the visit LPA observed a Little Tikes car in the infant play yard. Crystal Risner, Teacher who observed the incident described the incident and noted that C1 was in the fisher price car outside and started to crawl out. C1 fell forward, hitting his forehead on the concrete bike path. C1 was quickly picked up and comforted. C1 face was checked and teacher observed a pea size bump on the right side of C1's forehead, an ice pack was applied to C1's forehead. Teacher then brought C1 to the Ruby Alcantar, Supervisor to inform her of the incident. The Supervisor notified mother of the incident. The mother inquired on how C1 was doing. The Supervisor stated C1 was doing good and had returned outside and was playing. C1's mother stated "let me know of any changes and she would come pick up C1. No unusual behavior was observed, and mother picked up at normal pick up time.

THIS REPORT CONTINUES ON LIC809C.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 387-5041
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019
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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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 - STEP BY STEP EARLY HEAD START
FACILITY NUMBER: 406206384
VISIT DATE: 12/19/2019
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During the incident investigation revealed the Little Tike Car per manufacture posted on the Little Tikes car to state "This is intended for use by children from ages over 1/2 to five years of age.

LPA obtained a copy of the children's roster and interviewed the teacher who observed the incident.

No citations were issued during this visit.

LPA observed Licensee post the Notice of Site visit
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 387-5041
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2019
LIC809 (FAS) - (06/04)
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