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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 406215575
Report Date: 10/06/2020
Date Signed: 10/07/2020 05:09:03 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/11/2020 and conducted by Evaluator Gigi Reyes
COMPLAINT CONTROL NUMBER: 17-CC-20200611103003
FACILITY NAME:COLES FCC AKA ADVENTURE DAY CAMPFACILITY NUMBER:
406215575
ADMINISTRATOR:KIMBERLY MAE COLESFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(805) 610-4961
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:14CENSUS: 4DATE:
10/06/2020
UNANNOUNCEDTIME BEGAN:
05:03 PM
MET WITH:Kimberly ColesTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Licensee is not following the guidelines for use of the trampoline
INVESTIGATION FINDINGS:
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On 10/6/2020, 5:03 PM, Licensing Program Analyst (LPA) Gigi Reyes conducted an inspection to conclude a complaint investigation regarding the above allegations. Due to COVID-19 and Department of Public Health's guidelines pertaining to social distancing, a tele-inspection via facetime was conducted. LPA Reyes met with Licensee, Kimberly Coles.

Regarding the allegation Licensee is not following the guidelines for use of trampoline, complainant reported that children below 6 years old and more than one child use trampoline at a time. LPA interview with Licensee on July 3, 2020 revealed Licensee stated that 2 children at a time use the trampoilne with complete supervision. Licensee also stated that children age 2 years old and above use the trampoline provided there is waiver from the day care children parents.

Continued on LIC 9099 C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 17-CC-20200611103003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: COLES FCC AKA ADVENTURE DAY CAMP
FACILITY NUMBER: 406215575
VISIT DATE: 10/06/2020
NARRATIVE
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During the Pre Licensing inspection , Trampoline Conditions were stated in the LIC 809 Evaluation Report "Only children at least 6 years of age may use the trampoline and only one child at a time shall use the trampoline per manufacturer’s instructions.

LPA Velazquez interview with parents corroborated with the allegation.

Based on LPAs observation, interviews conducted the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED.

Exit interview was conducted with Licensee Kimberly Coles, a copy of the Appeal Rights (LIC 9058 FAS 01/16) were given and explained. Licensee’s signature on this form acknowledges receipt of these rights.

Notice of Site Visit has been posted (LIC9213). The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty. The following deficiency is being cited in accordance to Title 22 of the California Code of Regulations 102423 (a) (2) and/or Health & Safety codes. Please refer to LIC9099D for documentation of deficiency cited.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 17-CC-20200611103003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117

FACILITY NAME: COLES FCC AKA ADVENTURE DAY CAMP
FACILITY NUMBER: 406215575
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2020
Section Cited
CCR
102423(a)(2)
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(a) Each child receiving services from a family child care home shall have certain rights... (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.
This requiremen is not met as evidenced by:
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Licensee agreed to submit a plan of correction stating that Trampoline Conditions will be implemented. Letter must be received by Community Care Licensing Division (CCLD) no later than 10/16/2020.
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Based on LPA interview with Licensee and parents of day care children, two (2) children at a time, age 2 years old use the trampoilne with complete supervision. This is in violation of Trampoline Conditions and this posses a potential risk to health and safety of children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/11/2020 and conducted by Evaluator Gigi Reyes
COMPLAINT CONTROL NUMBER: 17-CC-20200611103003

FACILITY NAME:COLES FCC AKA ADVENTURE DAY CAMPFACILITY NUMBER:
406215575
ADMINISTRATOR:KIMBERLY MAE COLESFACILITY TYPE:
810
ADDRESS:5850 CASCABEL ROADTELEPHONE:
(805) 610-4961
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:14CENSUS: 4DATE:
10/06/2020
UNANNOUNCEDTIME BEGAN:
05:03 PM
MET WITH:Kimberly ColesTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Pool does not have a gate or pool cover
INVESTIGATION FINDINGS:
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On 10/6/2020 at 5:03 PM, Licensing Program Analyst (LPA) Gigi Reyes conducted an inspection to conclude a complaint investigation regarding the above allegations. Due to COVID-19 and Department of Public Health's guidelines pertaining to social distancing, a tele-inspection via facetime was conducted. LPA Reyes met with Licensee, Kimberly Coles.

Regarding allegation pool does not have a gate or pool cover, Complainant reported complainant's child talked about a swimming pool at daycare in which complainant was not aware off. During pick up time, unknown date, Complainant observed an inflatable pool in the backyard without covered nor fenced. On July 6 and 8, 2020, LPA interview with parents of day care children revealed parents did not observe inflatable pool, also their day care children have not mentioned being in a pool at day care. No parents corroborated with the allegation.

.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 17-CC-20200611103003
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE., SUITE 200
GOLETA, CA 93117
FACILITY NAME: COLES FCC AKA ADVENTURE DAY CAMP
FACILITY NUMBER: 406215575
VISIT DATE: 10/06/2020
NARRATIVE
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On July 3, 2020 during the physical plant tour, LPA did not observe inflatable water pool. On 10/6/2020 LPA interviewed Licensee, Licensee denied the allegation. Licensee stated there was inflatable pool one time, however water was dumped when not in use.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was conducted with Licensee Kimberly Coles, a copy of the Appeal Rights (LIC 9058 FAS 01/16) were given and explained. Licensee’s signature on this form acknowledges receipt of these rights.



Notice of Site Visit has been posted (LIC9213). The notice shall be posted for 30 consecutive days. Failure to maintain posting as required will result in a $100.00 civil penalty.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5