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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406213418
Report Date: 04/21/2023
Date Signed: 04/28/2023 02:50:23 PM


Document Has Been Signed on 04/28/2023 02:50 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 - CUESTA HEAD START - RM 4011FACILITY NUMBER:
406213418
ADMINISTRATOR:ADRIANA BARRONFACILITY TYPE:
850
ADDRESS:4000 CHORRO VALLEY RD.TELEPHONE:
(805) 546-3100
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93405
CAPACITY:20CENSUS: 11DATE:
04/21/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Kellie FisherTIME COMPLETED:
02:00 PM
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On 4/21/23 at 1:05 PM, Licensing Program Analyst (LPA) Francisca Velazquez met with facility representative, Kellie Fisher of the abovementioned Child Care Center (CCC), to follow up on the report of an Unusual Incident Report (UIR) received by the Department on 3/25/23 for an incident that occurred on 3/9/2023. Specifically, the incident involved a child in care, C1, being taken to a medical facility after tripping on his foot and falling forward, catching himself with his arms.

Facility representative informed LPA, C1 feel and stated his arm hurt. C1 was provided with ice pack and after a few minutes calmed down and continued to play. CCC completed injury report to provide to parent. On 3/13/23, parent informed CCC that C1 was taken to ER and was diagnosed with sprained wrist. Facility representative informed LPA C1 has returned to the CCC and is in good health. Further, C1 has no prolonged effects related to the incident. C1 has full mobility of his wrists.

LPAs contacted the parent (P1) of C1, who provided an account of the incident. As noted P1 describes C1 to be in good health at this time.

Following the incident C1 has not experience any medical issues. The incident is best categorized as an accident.

Notice of site visit was provided and must remain posted for 30 days. Exit interview and report was reviewed with facility representative, Kellie Fisher.

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023
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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