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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 406215266
Report Date: 01/12/2022
Date Signed: 01/12/2022 03:25:16 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:COUNTRY COTTAGE PRESCHOOLFACILITY NUMBER:
406215266
ADMINISTRATOR:BRIANNA MALLORYFACILITY TYPE:
850
ADDRESS:2075 JOHNSON AVENUETELEPHONE:
(805) 235-2153
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY:62CENSUS: 44DATE:
01/12/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kimberly Barrientos TIME COMPLETED:
01:00 PM
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On 1/12/22, Licensing Program Analyst (LPA) Elvin Baddley conducted an unannounced Case Management inspection of the abovementioned Child Care Center (CCC), to follow up on an Unusual Incident Report (UIR) by the Department on 1/11/22 concerning an unresponsive child, herein C1. LPA notes CCC staff contacted medical personnel, via a 911 call on 1/11/22, following C1 being unresponsive during a nap period.

LPA met with Kimberly Barrientos, Assistant Director of the CCC and explained the nature of the inspection. LPA notes 44 children are on site along with 5 teachers providing care and supervision.Assistant Director is also assisting with the care and supervision of children at the time of the inspection.

C1 is not on site but C1 is said to be in the care of guardians according to Assistant Director. Assistant Director informed LPA an email was received from the parent's of C1 noting C1's medical status. According to the correspondence, C1 had a febrile seizure on 1/11/22, due to a fever caused by a common cold. Assistant Director informed LPA C1's temperature was checked during entry to the CCC and immediately before emergency personnel arrived at the CCC. C1's temperature was not in excess of 100.4 and he did not have fever like when checked. C1 is doing fine according to C1's parent and C1's parent are assessing the likelihood of a return to the CCC given the C1's medical condition.

LPA spoke to the Assistant Director, who was also the staff member who notice C1's breathing during nap was abnormal. Assistant Director noted nothing prior to the incident which would have suggested C1 was had a cold or was having febrile seizures.

No deficiencies are cited during today's inspections and a Notice of Site Visit to be posted along with Appeal Rights is being provided to the Assistant Director .
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Elvin BaddleyTELEPHONE: (805) 635-4697
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2022
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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