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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421710360
Report Date: 03/21/2022
Date Signed: 03/21/2022 01:46:10 PM


Document Has Been Signed on 03/21/2022 01:46 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:PACIFIC CHRISTIAN SCHOOLFACILITY NUMBER:
421710360
ADMINISTRATOR:CALDERWOOD, MAUREENFACILITY TYPE:
850
ADDRESS:3435 SANTA MARIA WAYTELEPHONE:
(805) 938-7555
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY:90CENSUS: 73DATE:
03/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:21 AM
MET WITH:Maureen Calderwood and Sonja WittliebTIME COMPLETED:
12:00 PM
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On 3/21//2022 at 8:50 AM, Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced Case Management Inspection. LPA Reyes asked pre screening questions related to COVID 19, Asistant Director's responses indicate there are no COVID -19 exposure on site. LPA met with Assistant Director and explained the purpose of the inspection. There were 73 children and 11 teachers present. LPA toured the Child Care Center (CCC) in the company of the Assistant Director. Director Maureen Calderwood was conducting children's evaluation when LPA arrived.

On 3/11//2022, Child Care Center self reported an incident that Child # 1 sustained injury at the back of C1's head. It was reported that C1 and C2 were playing and started to wrestle/push each other. C1 was pushed by C2 causing C1 to fall backward and hit the back of the head on a book shelf. CCC Staff applied first aid and simultaneously contacted the parents. Child #1's injury required medical treatment.

Staff 1, the classroom teacher and who witnessed the incident was not present at the time of the inspection. LPA interviewed the Assistant Director who stated that shelf was moved into the corner out of the children's activity/playing space. There were 4 students and one teacher when the incident occurred.

continued on LIC 809 C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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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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: PACIFIC CHRISTIAN SCHOOL
FACILITY NUMBER: 421710360
VISIT DATE: 03/21/2022
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LPA interviewed Child # 1 who stated that during a circle time activity 2 children were competing to get first in to the activity, C2 pushed C1 causing C1 to fall and hit C1's back of the head into the book shelf. Child # 2 admitted C2's action and C2 was apologetic. Both children recounted "Ms. S" (Staff 1) was present in the classroom.

LPA inspected the classroom and observed that the book shelf edge is sloped and has a plastic lamination on the edge.

During today's inspection no deficiency was cited. Exit interview was conducted with Director, Maureen Calderwoood.

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: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
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