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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 426200008
Report Date: 05/14/2019
Date Signed: 05/14/2019 11:52:21 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 - ADAM CENTERFACILITY NUMBER:
426200008
ADMINISTRATOR:RALPH YBARRAFACILITY TYPE:
850
ADDRESS:500 W. WINDSOR ST.TELEPHONE:
(805) 925-6667
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:24CENSUS: 17DATE:
05/14/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:51 AM
MET WITH:Rebecca Romero TIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Martina Jimenez and Melissa Stewart made an unannounced CASE MANAGEMENT- INCIDENT inspection to the center. LPAs met with Rebecca Romero, Site Supervisor and explained the purpose of the visit to follow-up on an incident that was self reported to the department on 4/16/19. A tour of the facility was conducted inside and outside.


Site Supervisor and staff will be actively supervising children at all times. The staff has removed the table from the center and relocated the bookshelf against the wall on the same day of the incident, making the bookshelf secure from tipping over on to children in care.


LPAs observed "The Notice of Site Visit" posted. No deficiency cited. FAILURE TO POST THE NOTICE OF SITE VISIT FOR 30 DAYS MAY RESULT IN A $100 CIVIL PENALTY.
SUPERVISOR'S NAME: Maria MuellerTELEPHONE: (805) 387-5041
LICENSING EVALUATOR NAME: Martina JimenezTELEPHONE: (805) 387-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2019
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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