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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421712020
Report Date: 02/09/2022
Date Signed: 02/17/2022 04:21:04 PM


Document Has Been Signed on 02/17/2022 04:21 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: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: 25DATE:
02/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Carla Ayala & Bertha Heredia TIME COMPLETED:
12:30 PM
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On 2/9/22, Licensing Program Analyst (LPA) Francisca Velazquez conducted an unannounced Case Management inspection of the abovementioned Child Care Center (CCC), to follow up on an unusual incident report received on 1/26/22 indicating that C1 kicked C2 in the face/nose causing C2's nose to bleed. C1 and C2 were playing and C1 became upset and kicked C2. LPA met with the Carla Ayala, Site Supervisor of the CCC and explained the nature of the inspection. LPA notes 25 preschool children are on site being cared for by four (4) teachers and one (1) aide providing care and supervision. LPA notes that CCC cook and family service advocate were present at the CCC as well.

LPA discussed the incident with the Site Supervisor. Site Supervisor explained that C1 and C2 were playing in the sand area by the tires. At the time of the incident, S1 was outside supervising 10 children (count includes C1 and C2). Teaching staff reported noticing that C1 was getting upset and starting walking towards C1 to provide redirection. As teaching staff walked towards children, C1 kicked C2 in the face/nose causing C2’s nose to bleed. Teaching staff provided assistance to C2 by escorting C2 into the CCC and requested assistance from Site Supervisor. Site Supervisor then provided first-aid assistance by helping child wash hands and face and applied an ice pack. Site Supervisor reported having a conversation with both children about respecting personal spaces and also communicate with guardians of both families. Parent of C1 informed site supervisor that there are many changes in the family right now and stated she would talk to C1 about the situation. Site supervisor offered parent of C1 additional family resources by creating a Behavior Intervention Plan (BIP) for C1 to help child cope with all the changes occurring at home.

Site Supervisor reported that both C1 and C2 returned to the CCC and have continued to attend the CCC since the incident. C1 and C2 continue to be friends and frequently play together.

Based on the aforementioned, it is determined no violations have occurred, thus no deficiencies are cited during this inspection.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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: CAC - SIERRA MADRE CENTER
FACILITY NUMBER: 421712020
VISIT DATE: 02/09/2022
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Site supervisor is provided Appeal Rights as well as a Notice of Site Visit form to be posted.

On 2/9/22 at around 4:00 PM, LPAs laptop went on consistency check. LPA left the facility and explained to site supervisor that LPA will return at a later day to gather signatures for reports written on 2/9/22. LPA returned on 2/17/22 and met with facility representative, Bertha Heredia to review and sign reports.

SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Francisca VelazquezTELEPHONE: (805) 883-8244
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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