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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406206830
Report Date: 12/03/2021
Date Signed: 12/03/2021 02:47:29 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:SAN LUIS OBISPO CHILD DEVELOPMENT CENTERFACILITY NUMBER:
406206830
ADMINISTRATOR:MICHELLE HOLMFACILITY TYPE:
850
ADDRESS:1720 BISHOP ST.TELEPHONE:
(805) 544-0801
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:83CENSUS: 39DATE:
12/03/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kali ColeckTIME COMPLETED:
03:00 PM
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On 11/5/21, Licensing Program Analyst (LPA) Elvin Baddley contacted an unannounced Case Management inspection of the abovementioned Child Care Center (CCC), to follow up on the report of an Unusual Incident Report (UIR) received by the Department on 11/18/21. Specifically, a child in care, Jose Nicholas Beltran Zarate (DOB:2/28/17 ), herein C1, fractured left arm (lower).after slipping from the monkey bars of a play structure in the CCC's outdoor play area. LPA met with Kali Coleck, Program Manager of the CCC and explained the nature of the inspection. LPA notes 39 children are on site along with 12 teachers providing care and supervision.

LPA and Program Manager viewed the play structure where C1 slipped from. LPA notes the play structure is age appropriate and the footing under the structure has ample cushioning material (i.e. wood chips and cushion mat) to absorb falls. Program Manager notes teachers serve as spotter when children are using the play structure's monkey bars. LPA notes C1 is currently attending the CCC and has a hard cast on the injured area. Staff report C1 has not prolonged issues related to the injuries.

Based on observations and the interview with the Program Manager it is determined neither the equipment at the CCC nor the actions of the CCC's staff contributed to C1's incident. LPA best categorized the incident as an accident.



SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin BaddleyTELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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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