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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421712020
Report Date: 01/16/2020
Date Signed: 01/16/2020 11:25:36 AM

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 - SIERRA MADRE CENTERFACILITY NUMBER:
421712020
ADMINISTRATOR:CASSANDRA HARTFACILITY TYPE:
850
ADDRESS:1002 E. SIERRA MADRE AVE.TELEPHONE:
(805) 349-9707
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:50CENSUS: 29DATE:
01/16/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Carla AyalaTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA), Melissa Stewart, conducted an unannounced inspection and met with Program Manger, Kim Eichert and Site Supervisor, Carla Ayala. LPA explained that the purpose of the inspection was to follow up on an written Unusual Incident Report (UIR) dated 12/23/19 which was received at the Community Care Licensing (CCL) office on 12/24/19. Site Supervisor and Program Manager accompanied LPA on a tour of the center. At time of inspection there were 10 children supervised by 3 staff in the Extended Day classroom and 19 children supervised by 2 staff in the Full Day Classroom.

Per the center's self-report, Staff # 1 (S1) observed an incident which occurred on Tuesday, 12/17/19. LPA interviewed S1 regarding the incident and observed the area where the incident occurred. S1 reported that child #1 (C1) and child #2 (C2) were hugging each other after group time as they were preparing to wash hands for lunch at approximately 11:45am. C2 lost balance and the two children fell. S1 helped children up. C1 was crying and holding C1s forearm. S1 felt C1s arm and applied ice to the wrist. S1 continued to observe C1 throughout lunch and nap time. S1 stated that C1 was protective of C1s wrist and stated "it hurts." S1 informed parent of C1 of the incident when parent arrived to pick up C1 who was signed out at 2:41pm. S1 encouraged C1s parent to take C1 to the doctor for evaluation. C1 returned to the center the following day (12/18/19) and left early for a medical appointment. The physician determined that C1 sustained a fracture. Site Supervisor reported that there were 14 children supervised by 2 staff at time of incident.
Continued on 809-C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020
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: CAC - SIERRA MADRE CENTER
FACILITY NUMBER: 421712020
VISIT DATE: 01/16/2020
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Based on file review and interviews conducted, there was appropriate supervision at the time of the incident, staff applied basic first aid, continued to observe the child and encouraged the parent of the child to seek professional medical attention.

No deficiencies are being issued as a result of this incident.

LPA observed Notice of Site Visit posted.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Melissa K StewartTELEPHONE: (805) 689-6267
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2020
LIC809 (FAS) - (06/04)
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