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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 426200008
Report Date: 06/02/2022
Date Signed: 06/02/2022 06:58:22 PM

Substantiated


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
05/31/2022 and conducted by Evaluator Martina Jimenez
COMPLAINT CONTROL NUMBER: 17-CC-20220531144116
FACILITY NAME:CAC - ADAM CENTERFACILITY NUMBER:
426200008
ADMINISTRATOR:STACEY LARAFACILITY TYPE:
850
ADDRESS:500 W. WINDSOR ST.TELEPHONE:
(805) 925-6667
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:24CENSUS: 10DATE:
06/02/2022
UNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Stacey LaraTIME COMPLETED:
07:15 PM
ALLEGATION(S):
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Personal Rights - Staff not preventing day-care children from bullying other day-care children
Reporting Requirements - Facility not reporting unusual incidents to CCL
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Martina Jimenez made an unannounced visit for the purpose of initiating a complaint investigation into the above allegations. LPA met with Stacey Lara, Site Supervisor and discussed the nature of the visit. LPA toured the facility accompanied with staff. LPA conducted interviews with staff.

The allegation stated staff not preventing day-care children from bullying other day-care children. During this investigation, LPA made one unannounced visit and interviewed staff. It was confirmed by staff interviews that child#1, child #2, Child #3, and child #4 are constantly aggressively hitting, spitting, and cursing at the children, and the staff. The staff have to run to protect the day-care children and act as a shield, while being hit by the aggressive child. Child #1 has destroyed the playground on two (2) separate occasions throwing toys, books, up rooting plants and attempting to hit day-care children and staff. Child #2 climbs to the top of the play structure and stands on top of the play structure, while staff attempts to get the child to climb down off the top of the play structure.
Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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 4
Control Number 17-CC-20220531144116
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: CAC - ADAM CENTER
FACILITY NUMBER: 426200008
VISIT DATE: 06/02/2022
NARRATIVE
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Facility staff acknowledged the incidents have occurred, and did not file an unusual incident report to CCLD.
The facility staff advised how they have addressed the issue with the children involved. Children parents were contacted and informed of the incident. Facility staff have been working with children involved in the incidents and their parents.

Based on LPA's observations, staff interviews, and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number 1), are being cited on the attached LIC 9099D.

Site Supervisor was provided appeal rights and copy of regulation cited.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 17-CC-20220531144116
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: CAC - ADAM CENTER
FACILITY NUMBER: 426200008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited
CCR
101223(a)(1)
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101223 Personal Rights
(a) The licensee shall ensure that each child is accorded the following personal rights:
(1) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation ...withholding of shelter, clothing, medication or aids to physical functioning.
This requirement is not met as evidence by:
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Site Supervisor will submit a written plan on how they will ensure children's personal rights are not violated and ensure the environment is safe. Submit the written plan to CCL by 6/3/2022.
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Based on interviews conducted, the center failed to ensure the child's personal rights were not violated. Children constantly aggressively hitting, spitting, and cursing at the children, and the staff. The staff have to run to protect the day-care children and act as a shield, while being hit by the aggressive child. Child #1 has destroyed the playground on
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two (2) separate occasions throwing toys, books, up rooting plants and attempting to hit day-care children, and staff. Child #2 stands on top of the play structure. This poses an immediate health and safety risk to clients/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.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 17-CC-20220531144116
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: CAC - ADAM CENTER
FACILITY NUMBER: 426200008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
101212
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(d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be
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Site Supervisor will submit a written plan on how they will ensure to report all unusual incidents to CCLD within 24 hours of the incident, and submit a written report within 7 days of the incident by 6/10/2022.

Martina.Jimenez@dss.ca.gov
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submitted to the Department within seven days following the occurrence of such event. (C) Any unusual incident or child absence that threatens the physical or emotional health or safety of any child. This requirement is not met as evidence by: The facility failed to report the
incident(s) of children bullying, hitting and
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injuries to Community Care Licensing (CCL). This poses a potential health & safety risk to 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.
SUPERVISORS NAME: Maria Mueller
LICENSING EVALUATOR NAME: Martina Jimenez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4