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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421709268
Report Date: 02/25/2020
Date Signed: 02/25/2020 01:41:42 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:CAC - GOLETA I CENTERFACILITY NUMBER:
421709268
ADMINISTRATOR:BETTY SANCHEZFACILITY TYPE:
850
ADDRESS:5681 HOLLISTER AVENUETELEPHONE:
(805) 967-7684
CITY:GOLETASTATE: CAZIP CODE:
93117
CAPACITY:45CENSUS: 17DATE:
02/25/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Molly JarvisTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ruth Gull made an unannounced CASE MANAGEMENT visit to the center. Met with Molly Jarvis, Site Supervisor to follow up on an incident that was self-reported by the center on 02/21/20. LPA toured the playground where the incident occurred and interviewed Site Supervisor, Teacher #1, Teacher #2 and Teacher #4. LPA obtained copies of pertinent sign in/out and tracking documents.

The incident occurred on 02/20/20 at approximately 9:45am. There were 17 children with 3 teachers and 1 adult volunteer present at the time of the incident. The incident occurred on the playground and the children were lining up at the exit gate to walk to the tennis court (on site, across the parking lot). Teacher #2 was at the front of the line and completed a head count as the children lined up holding hands. Teacher #3 was standing by the middle of the line and Teacher #4 obtained the backpack and tracking sheet located by the entrance door to the classroom (inside the playground). Teacher #2 stated that she counted 17 children (which was the number of children present at the time) and Teacher #2 started leading the children out of the gate and down the walkway. Teacher #4 walked up to the back of the line and took hold of the last child's hand. Teacher #4 didn't complete a name check at the time as Teacher #2 had stated the correct number of children present. The group walked over to the tennis court, entered, and the children sat down. Teacher #2 completed another head count, realized that Child #1 was missing, and observed Teacher #1 walking with Child #1 to the tennis court. Teacher #1 had been on break and returned right after the group left the playground. Teacher #1 was walking past the playground when she observed Child #1 standing in the corner of the playground looking out at the walkway. Child #1 did not appear to be upset (not crying). Teacher #1 and Child #1 walked to the tennis court and joined the group (after they went to the office to return the bathroom key and then to the classroom so that Teacher #1 could obtain something from her purse). Child #1 could not say specifically why he got out of line or where he went as they were lined up. Staff interviews and LPA observations indicate that Child #1 was left alone on the playground for less than 5 minutes.
CONTINUED ON LIC 809-C
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Ruth GullTELEPHONE: (805) 895-4073
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: CAC - GOLETA I CENTER
FACILITY NUMBER: 421709268
VISIT DATE: 02/25/2020
NARRATIVE
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Pursuant to Title 22 of the CA Code of Regulations, the following Type B deficiency was cited (refer to LIC 809-D). The Site Supervisor was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. The LIC9213 (Notice of Site Visit) was posted during the visit.
SUPERVISOR'S NAME: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Ruth GullTELEPHONE: (805) 895-4073
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: CAC - GOLETA I CENTER
FACILITY NUMBER: 421709268
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/03/2020
Section Cited

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101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).
This requirement was not met as evidenced by interviews with Director and staff and LPA observations reveal that on 2/20/20
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Child #1 was left on the playground unattended for less than 5 minutes. This poses a potential risk to the safety of the children.
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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: Ana TolentinoTELEPHONE: (805) 562-0437
LICENSING EVALUATOR NAME: Ruth GullTELEPHONE: (805) 895-4073
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3