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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426200008
Report Date: 06/21/2022
Date Signed: 06/21/2022 04:38:31 PM


Document Has Been Signed on 06/21/2022 04:38 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 - 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: 13DATE:
06/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Angelica HErnandez DiazTIME COMPLETED:
04:40 PM
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On June 21, 2022 at , Licensing Program Analyst (LPA) Gigi Reyes conducted an unannounced 1 Year Required Inspection and met with Site Supervisor Ms. Angelica Hernandez-Diaz who covers for the above Child Care Center's (CCC) current Site Supervisor, Ms. Stacey Lara. LPA explained the purpose of the inspection. Prior to inspection LPA asked screening questions related to COVID -19 and SIte Supervispr's Responses responses indicate there are no COVID-19 exposure on site. The CCC is located in the ground of Adam Elementary School . The CCC operates Monday to Friday 7:00 AM to 5:30 PM.

LPA in the company of Ms. Hernandez-Diaz toured the Center inside and out. There were 13 day care children and 4 staff present. Licensing required forms and Licensing evaluation reports are posted in the wall. The current snack menu is also posted. The outdoor playground is enclosed with the wire fences. The outside space has age appropriate toys and equipment. The playground has an ample amount of sand cushioning. The center has drinking water available for children inside and out.

Sign in/sign out was reviewed and meets the regulation requirements. A sampling of children records were reviewed and found complete, it contains Identification and Emergency card information. Staff records were reviewed and found complete. Site Supervisor and Staff qualifications were verified. Teachers present have current Pediatric First Aid/CPR certificates that expire on 8/2/2023. LPA verified SB 792 Child Care Adult Immunization record and tuberculosis requirements.

Continued on LIC 809C
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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: CAC - ADAM CENTER
FACILITY NUMBER: 426200008
VISIT DATE: 06/21/2022
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No deficiencies were cited during today's visit.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Site Supervisor was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Site Supervisor, Ms. Angelica Hernandez-Diaz.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 562-0410
LICENSING EVALUATOR NAME: Gigi ReyesTELEPHONE: (805) 698-7114
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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